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Objective: To estimate the proportion and characteristics of U.S. pediatricians who reportedly counsel their patients about maintaining a healthy weight.
Research Methods and Procedures: Beginning in October 1998, information was collected from 813 primary care pediatricians randomly selected from a nationally representative sample. Pediatricians were asked how frequently they counseled about maintaining a healthy weight during the well-care visits of patients in three age groups. Multivariable logistic regression determined which physician characteristics were associated with counseling.
Results: Approximately fifty percent of pediatricians reportedly always counseled about maintaining a healthy weight. Those who always counseled were more likely to be women, to spend more time with patients during well-care visits, and to conduct more well-care visits per week from patients in one particular age group. Most pediatricians who responded that they always counseled about healthy weight reported that they counseled about physical activity and nutrition, but not about balancing caloric intake with expenditure.
Discussion: Although many pediatricians report counseling about healthy weight, the frequency of counseling might be further increased by increasing the amount of time the patient spends during office visits with the pediatrician or with other professional staff, such as nurses or dieticians.
Overweight and obesity are complex multifactorial conditions and are among the most burdensome public health problems we face. National data indicate that during the past two decades, the percentage of children who are overweight, defined as a BMI ≥95th percentile for age and gender, has tripled for children and adolescents (1). Although obesity-associated morbidities occur most frequently in adults, important consequences of excess weight, as well as antecedents of adult disease, occur in overweight children and adolescents (2). Overweight children and adolescents are more likely to become overweight or obese adults (3). This concern is greatest among adolescents (3). Type 2 diabetes, high blood lipids, hypertension, early maturation in females, orthopedic problems, and psychosocial consequences, particularly discrimination, are associated with overweight in children and adolescents (2).
By alerting patients to the risks of excessive weight gain and advocating lifestyles that promote a healthy weight, physicians have an important role in helping patients prevent the development of obesity. Numerous government and professional organizations recommend that physicians who treat children and adolescents should counsel about the importance of regular physical activity and healthy eating. There is greater variability in recommendations for counseling about maintaining a healthy weight (Table 1) (4, 5, 6, 7, 8). Some guidelines advise physicians to counsel all patients specifically about maintaining a healthy weight (5, 6). Others recommend that adolescents receive annual health guidance about safe weight management, but do not mention weight counseling for younger children (4, 8).
Table 1. . Guidelines for healthy-weight counseling
USDHHS, U.S. Department of Health and Human Services.
For up to age 11 years, recommends providing guidance for healthy eating and encouraging regular physical activity. For ages ≥11 years, recommends discussing achieving and maintaining a healthy weight through appropriate eating habits and regular physical activity.
Clinicians Handbook of Preventive Services (Ref. 5)
USDHHS, Office of Disease Prevention and Health Promotion
Primary care clinicians should counsel children, adolescents, and their parents about the importance of maintaining a healthy weight.
All patients should receive appropriate counseling to promote physical activity and a healthy diet. Both diet and exercise should be designed to achieve and maintain a desirable weight by keeping caloric intake balanced with energy expenditures.
Guidelines for Adolescent Preventive Services (GAPS) (Ref. 7)
American Medical Association
All adolescents should receive health guidance annually about dietary habits, including ways to achieve a healthy diet and safe weight management.
For up to age 11 years, recommends providing guidance about eating a balanced diet and avoiding junk food and also recommends regular physical activity. Recommendations to maintain a healthy weight by eating a good and sensible diet, routine exercise, and avoiding crash diets, medications, laxatives, or forced emesis begin at age 12 years.
Few studies provide information about whether physicians discuss healthy weight with their young patients (children or adolescents) or with the patients’ caregivers (9, 10, 11). Furthermore, little information is available regarding characteristics of physicians who counsel on this topic in any age group. Our study examined the proportion of U.S. pediatricians who reportedly counseled children and adolescents, 2 to 18 years of age, about maintaining a healthy weight and the demographic and practice characteristics of the pediatricians who counseled. In addition, we present the proportion of pediatricians who reported counseling about other weight-related topics.
Research Methods and Procedures
The target population for this survey were pediatricians in primary care practice who treated 10 or more children or adolescents (ages 2 to 18 years) per week. Potential participants were selected from the American Medical Association (AMA)1 physician “masterfile,” a comprehensive list of practicing physicians (both members and nonmembers of AMA) in the U.S. (12).
In June 1998, 61, 172 physicians in the AMA physician masterfile identified themselves as pediatricians. To achieve a representative sample, pediatricians with the following characteristics were eliminated before random selection: doctors of osteopathy, because they may have had different training with regard to prevention (n = 1151); physicians with disciplinary actions (n = 757); physicians who were deceased or whose death status was being determined (n = 3996); physicians who were born before 1938, because they were likely to be retired (n = 9411); physicians who graduated from medical school after 1995, because they were likely to be residents (n = 6879); physicians who did not provide direct patient care (n = 8977); and physicians who were foreign medical school graduates practicing temporarily in the U.S. or who were U.S. citizens practicing in foreign countries (n = 666). Using these exclusion criteria, 29, 335 physicians were eligible for our selection. Of these physicians, the following were eliminated for practical reasons related to the conduct of the study: those who did not provide a U.S. mailing address (n = 1556); those who did not provide a telephone number (n = 11, 683); and those who asked not to be contacted (n = 183). Among the 29, 335 physicians eligible for selection, those physicians who were excluded for practical reasons (n = 13, 422) were not significantly different from those physicians who were not excluded (n = 15, 913), with regard to mean age, proportion who were men, proportion who were board certified, proportion who were foreign medical graduates, and proportion who were living in specific geographic regions. Among the remaining 15, 913 physicians, 1760 were randomly selected for this survey. This number was chosen to provide national prevalence estimates (± 4%) for counseling, assuming that 10% were ineligibles who were not detected through the sampling process and 40% were nonrespondents.
This study was designed primarily as a telephone survey. One week before the telephone survey began, all participants were sent a letter that described the study. The telephone survey was conducted between October 1998 and December 1998, and calls were made by trained interviewers who used a standardized questionnaire and who simultaneously entered data using a computer-assisted telephone system. At least eight attempts were made on various days and various times of day to contact each physician at his or her office. Physicians or their gatekeepers were provided a toll-free number to call and schedule interviews at their convenience. At the end of the 3-month period, 674 of the 1760 selected physicians (38%) were successfully contacted and screened. To improve the response rate, a written version of the questionnaire was mailed to all nonrespondents. After two mailings, an additional 338 pediatricians were successfully contacted and screened for eligibility. Thus, the total successful contact rate was 57.5% (1012 of 1760). A comparison between those who were successfully contacted and those who were not indicated no difference in mean age (45.3 vs. 46.1, respectively) or gender (55.0% men vs. 57.4% men, respectively). Among those contacted and screened either by telephone or by mail (n = 1012), 102 were not eligible for the study (15 were retired; 2 were medical residents; 29 did not identify themselves as pediatricians; 44 were not in primary care; and 12 treated <10 children or adolescents each week). Of the pediatricians who were determined to be eligible for the study, three declined to participate. Therefore, 907 pediatricians contacted were eligible to be included in our initial analysis.
Our analysis compared the healthy-weight counseling practices of pediatricians across three age groups of patients (2 to 5 years; 6 to 12 years; 13 to 18 years). Therefore, of the 907 eligible pediatricians, we excluded 56 because they did not see patients in each of the three age groups. Of the remaining 851, we excluded those who did not provide data on weight counseling (n = 4) and those who did not provide data on one or more covariates (n = 34). Our final analytic population included 813 pediatricians.
The questionnaire was designed to be administered by telephone in 15 to 20 minutes. Information collected included the demographic, behavioral, and medical practice characteristics of the pediatrician, as well as the counseling practices of the pediatrician with regard to nine preventive behaviors (including maintenance of a healthy weight). Because previous research has indicated that physician counseling practices might vary by the age of the patient (13), pediatricians were asked about their counseling practices for three age groups of patients: children 2 to 5 years of age; children 6 to 12 years of age; and adolescents 13 to 18 years of age. Although not formally validated, the questionnaire was reviewed by an advisory panel of experts in the fields of nutrition and physical activity for children and adolescents and was piloted among a small number of pediatricians. A copy of the questionnaire can be obtained on request from this report's corresponding author.
Definition of Counseling
For determining whether a pediatrician regularly counseled about maintenance of a healthy weight, the following question was asked: “Physicians may talk to their patients about health behaviors. Thinking about well-care visits or routine check-ups of your patients (in each of the three age groups) during the past month, how frequently did you talk to the child (or adolescent) or their caregiver about maintenance of a healthy weight?” Participants were asked to respond with one of the following: 1) always; 2) most times; 3) sometimes; or 4) never. Pediatricians who reported that they “always” counseled about maintenance of a healthy weight were defined as a “regular counselor.”
For each age group, pediatricians were asked how frequently they talked with the child (or adolescent) or caregiver about nutrition and about physical activity. Those who responded that they ever counseled about diet or nutrition (i.e., responded “always”, “most times,” or “sometimes” to the counseling question) were asked how frequently (“always”, “most times,” “sometimes,” or “never”) they counseled about balancing caloric intake with caloric expenditure.
Definition of Covariates
Nine covariates were selected for this analysis because of their previously hypothesized association with physician counseling. These variables included six demographic characteristics of the pediatricians: 1) their gender; 2) their age (<45 years vs. ≥45 years); 3) whether they were board certified; 4) whether they had a medical school appointment; 5) their region of practice (Midwest, Northeast, South, and West); and 6) their BMI values [defined by weight (in kilograms) divided by height (in meters) squared], which were calculated from self-reported weight and height (14). Three practice characteristics of the pediatricians were assessed: 1) the length of time for well-care visits for patients in each age group (<20 minutes vs. ≥20 minutes); 2) the number of patients in each age group seen for well-care visits per week (<10 patients/week vs. ≥10 patients/week); and 3) whether the pediatricians practiced in a staff-model health maintenance organization or in a private practice. For continuously scaled covariates, the rationale for category cut-off points was determined by one of two methods: 1) distributional (near median values across all age groups for age, number of patients seen per week for well-care visits, and length of time spent during well-care visits); or 2) biological (overweight classified as BMI ≥25.0 to 29.9 kg/m2; obesity classified as BMI ≥30.0 kg/m2) (14).
Statistical analyses were completed using SAS version 8.2 (SAS Institute Inc., Cary, NC). To evaluate whether a pediatrician's characteristics were associated with the pediatrician being a regular counselor about maintenance of a healthy weight, we used simple and multiple variable logistic regression.
Description of Population
The mean age of the analytic sample was 45 ± 8 years. Fifty-six percent of respondents were men, and the male respondents were 4 years older than the female respondents (47 ± 7 years vs. 43 ± 7 years). Geographically, respondents were fairly evenly distributed among the U.S. regions: Midwest (22%), Northeast (26%), South (31%), and West (21%). Most respondents were board certified (92%) and members of the American Academy of Pediatrics (90%). The majority of the pediatricians participated in private practice arrangements (19% single-doctor and 60% group-doctor practices); the remaining physicians participated in either a staff-model health maintenance organization (8%) or some other arrangement (13%). The mean pediatrician BMI by self-report was 24 ± 3 kg/m2, with lower BMI values reported by women compared with men (23 ± 3 vs. 25 ± 3, p < 0.05).
The number of children that pediatricians reported seeing per week for well-care visits and the average time spent with the child during the visit varied by the age of the child. Specifically, the number of patients seen per week for well-care was lower for adolescents (2 to 5 years: 28 ± 19; 6 to 12 years: 17 ± 13; 13 to 18 years: 10 ± 10; all groups were different, p < 0.05), and the average amount of time spent during the visit was higher for adolescents (2 to 5 years: 19 ± 6; 6 to 12 years: 19 ± 7; 13 to 18 years: 22 ± 9; the adolescent group was different, p < 0.05).
Prevalence of Counseling about Healthy Weight
Pediatricians reported frequently discussing the topic of maintaining a healthy weight with their patients; ∼50% reported always talking about the topic with children ages 2 to 5 years and 6 to 12 years, and 56% reported always talking about healthy weight with their patients ages 13 to 18 years (Figure 1). Three-fourths of pediatricians reported counseling children 2 to 5 years old about healthy weight either all or most of the time; these percentages are slightly higher in the older age groups. Almost all of the pediatricians surveyed reported counseling about healthy weight at least some of the time.
Several pediatrician characteristics were associated with the odds of always counseling about maintaining a healthy weight (Table 2). In bivariate analyses, characteristics significantly associated with increased odds of counseling in the three age groups included being a woman [odds ratios (ORs) range from 1.6 to 2.3], spending ≥20 minutes with patients (ORs range from 1.4 to 2.0), and seeing 10 or more patients for well-care visits per week (ORs range from 1.4 to 1.7). Counseling about healthy weight was not associated with the pediatricians’ age, their BMI, the location of their practice, their practice type, being board certified, or having a medical school appointment. After adjustment for all nine covariates, the associations between the predictor variables and counseling about a healthy weight remained consistent in the multivariate analyses (Table 3). Only those variables that were significantly associated with the outcome are presented.
Table 2. . Prevalence and unadjusted relative odds of always counseling about healthy weight by the patient's age, Physician Practices Survey, 1998 to 1999
Average time spent with child during well-care or routine visits (minutes)
1.4 (1.1 to 1.9)
1.8 (1.4 to 2.4)
2.0 (1.5 to 2.6)
Number of patients seen per week for well-care
1.7 (1.2 to 2.5)
1.4 (1.1 to 1.8)
1.5 (1.1 to 2.1)
0.9 (0.6 to 1.6)
1.0 (0.6 to 1.6)
1.3 (0.8 to 2.2)
Medical school appointment
0.9 (0.7 to 1.2)
1.0 (0.7 to 1.3)
1.0 (0.8 to 1.3)
Table 3. . Adjusted relative odds of always counseling about healthy weight by the patient's age, Physician Practices Survey, 1998 to 1999
Counseling about healthy weight by patient's age
2 to 5 years
6 to 12 years
13 to 18 years
# Always counsel
ORa (95% CI)
# Always counsel
ORa (95% CI)
# Always counsel
ORa (95% CI)
N = 813 pediatricians.
ORa, odds ratio adjusted for age, sex, BMI, board certification, region of the U.S., time spent with child during well-care visit, number of patients seen per week for well-care, practice setting, medical school appointment; CI = confidence interval.
1.5 (1.1 to 2.0)
2.3 (1.7 to 3.1)
2.2 (1.6 to 3.1)
Average time spent with child during well-care or routine visits (minutes)
1.4 (1.0 to 1.9)
1.8 (1.3 to 2.4)
1.7 (1.3 to 2.4)
Number of patients seen per week for well-care
1.9 (1.3 to 2.7)
1.5 (1.1 to 2.0)
1.7 (1.2 to 2.3)
Nutrition and Physical Activity Counseling among Pediatricians Who Always Counsel about Healthy Weight
Most physicians who always counseled about maintenance of a healthy weight also always counseled about physical activity and nutrition (Figure 2). Pediatricians who always counseled about healthy weight counseled about physical activity less in the 2-to-5 year age group compared with 6-to-12-year and 13-to-18 year age groups (72% vs. 85% and 89%, respectively). Approximately 90% of weight-counseling pediatricians always counseled patients about nutrition in all three age groups. Only 38% of pediatricians who always counseled about healthy weight responded that they always counseled the caregivers of patients in the 2-to-5-year age group about balancing caloric intake with caloric expenditure. The percentages were slightly higher for the 6-to-12-year (48%) and the 13-to-18-year (54%) age groups.
In this article, we describe the healthy-weight counseling practices of U.S. pediatricians by presenting the reported frequency of counseling, the demographic and practice characteristics of those who replied that they counsel, and the frequency of reported counseling about weight-related topics. The prevalence of purported counseling about maintenance of a healthy weight was relatively high. Approximately one-half of the pediatricians surveyed reported always discussing maintenance of a healthy weight with children or adolescents or their caregivers during well-care visits. Although some of the commonly used guidelines do not include the specific recommendation to counsel about maintenance of a healthy weight in the younger age groups, almost all pediatricians surveyed reported counseling about this issue at least some of the time.
It is difficult to compare our findings with other studies examining this topic because other surveys differ in the unit of analysis or the specific questions asked regarding the frequency of healthy-weight counseling or the type of visit. Our study is most similar to that of Frank et al., in which 72% of female pediatricians reported counseling yearly about healthy weight (9). The higher results in that study may have reflected that the pediatrician was considering all communications within a year's time, including those involving acute-care appointments. Similar to our results, but using a different unit of analysis, Bethel et al. found that 50.5% of adolescents reported that they had received counseling about diet, weight, and exercise from their physician (10).
Although not all pediatricians may always be counseling on this topic, our study suggests a relatively high frequency of weight counseling by pediatricians. Across all three age groups of patients, pediatricians who reportedly always counseled were more likely to be women, to see more patients per week, and to spend more time with the patient. Our results regarding gender are consistent with the evidence reviewed by Frank and Kunovich-Frieze, who found that female physicians of various specialties are more avid preventionists than men (15), and studies by Holund et al. (16) and Kristeller and Hoerr (17), which demonstrated that women are more likely to discuss weight management with their adult, overweight patients. Some have hypothesized that women are more likely to provide preventive health services because they spend more time with their patients (18); however, in our study, the effect of gender was evident even after controlling for the average length of the visit.
Our results suggest that physicians who spend more time with their patients are more likely to counsel about maintenance of healthy weight. These results are consistent with studies that found lack of time as a perceived barrier to counseling about health topics in adults (19, 20, 21). Cheng et al. found that perception of adequate time was not associated with pediatricians’ counseling about growth and nutrition (22). However, weight counseling, which may be prioritized lower than growth and nutrition for pediatricians, was not specifically addressed in Cheng's study. Time is an enabling factor and may be the deciding factor when a physician is attempting to prioritize multiple issues (23). The amount of time spent with patients is a characteristic that could potentially be addressed within the office setting, either by pediatricians ensuring adequate time for well-care visits or by using other professional staff to provide preventive counseling (e.g., nurses or dieticians). We found that seeing more patients per week for well-care visits in each age group was associated with always counseling about maintenance of a healthy weight. Few studies have examined the association between the number of patients and counseling practices. Frank et al. used a variable that could be considered a proxy (hours worked per week) and found that female primary care and specialist physicians who worked <40 hours per week were less likely to provide weight counseling (24). We hypothesize that physicians who repeat more frequently the same visit type may be more likely to incorporate the weight-recommended counseling behaviors into their routine.
Several physician characteristics (BMI, age, type of practice, board certification, practice location, and medical school appointment) were not observed to be associated with healthy-weight counseling in this study. Previous studies linking counseling about weight with physician BMI have shown inconsistent results (9, 25, 26). With regard to physician age, some studies have found that older physicians were more likely to counsel about weight (9, 13). Many investigators have not found an association between board-certification (24, 25) or practice type (24, 27), including practicing at a medical school (24), and practice of preventive counseling.
Our study also describes the frequency of counseling about other topics that are relevant to healthy weight. Most pediatricians who reportedly always discuss healthy weight also discuss nutrition and physical activity. However, most do not counsel about balancing caloric intake and caloric expenditure. Although counseling about caloric balance is specifically recommended in the U.S. Preventive Services Task Force guidelines (6), we hypothesize that pediatricians consider energy balance to be a topic that is difficult to communicate to families of growing children and adolescents. Nonetheless, caloric balance is an integral part of achieving and maintaining a healthy weight. Developing understandable and easily communicated messages regarding caloric balance might increase pediatrician counseling on this important topic.
Several limitations of our study, including issues associated with physician surveys, are commonly inherent in survey research. First, only half of the eligible sample participated in our study, although a separate analysis showed that respondents and nonrespondents did not differ by gender or age. Second, although reviewed by experts and pilot tested by multiple pediatricians, this survey instrument, similar to most physician counseling surveys, lacks formal validity testing. Whether the physicians’ reports resulted in an overestimation or underestimation of counseling is unclear. A previous study of adult patients comparing a post-visit physician survey with an audiotape found substantial agreement for both diet/weight and physical activity counseling behaviors (28). Third, we do not know the quality of the counseling interaction because the definition of counseling is not specifically stated. Another limitation of this study relates to the timeliness of the data. Given the general trend of increasing prevalence of overweight and obesity, physician attitudes may have changed since 1998 to 1999, when the data were collected.
Despite these limitations, our study provides important information supporting a high level of intention by pediatricians to address healthy-weight counseling. As the prevalence of overweight increases, this topic will only become more germane. Future research should be designed purposely to address topics related to weight counseling, including pediatricians’ confidence in their ability to guide behavior changes; pediatrician usage of behavior-change theories in practice, such as stages of change (29); and the effectiveness of physician/patient communication and healthy-weight counseling on changing behaviors. Research should address whether time is a barrier to counseling and, if so, whether longer visits or the use of other personnel, such as nurses or dieticians, to provide preventive services increases the prevalence of healthy-weight counseling. Future research may also be necessary to investigate whether different attitudes about childhood overweight in female vs. male pediatricians may help explain the difference in counseling about this topic and whether pediatricians with more frequent or longer well-care visits have a different attitude about general health-promotion counseling. The development of a validated questionnaire assessing pediatrician weight counseling would also be helpful in assisting future research.
In summary, half of the pediatricians in this study reported always counseling about healthy weight, and nearly all pediatricians reported counseling children and adolescents at least some of the time about maintenance of a healthy weight. As indicated by the high prevalence of counseling, our results suggest that physicians believe that maintenance of a healthy weight is an important topic to be addressed during well-care visits for children and adolescents.
We acknowledge the Centers for Disease Control and Prevention Foundation for its role in funding and administering this survey and members of the Physical Activity and Nutrition Advisory Board for their thoughtful review of the survey instrument.
Nonstandard abbreviations: AMA, American Medical Association; OR, odds ratio.