Address for correspondence: Dr G Ball, Department of Pediatrics, University of Alberta, Edmonton, AB T5K0L4, Canada. E-mail: email@example.com
In this integrative review, we examined contemporary literature in pediatric weight management to identify characteristics that contribute to the relationship between families and health professionals and describe how these qualities can inform healthcare practices for obese children and families receiving weight management care. We searched literature published from 1980 to 2010 in three electronic databases (MEDLINE, PsycINFO and CINAHL). Twenty-four articles identified family–health professional relationships were influenced by the following: health professionals' weight-related discussions and approaches to care; and parents' preferences regarding weight-related terminology and expectations of healthcare delivery. There was considerable methodological heterogeneity in the types of reports (i.e. qualitative studies, review articles, commentaries) included in this review. Overall, the findings have implications for establishing a positive clinical relationship between families and health professionals, which include being sensitive when discussing weight-related issues, using euphemisms when talking about obesity, demonstrating a non-judgmental and supportive attitude and including the family (children and parents) in healthcare interactions. Experimental research, clinical interventions and longitudinal studies are needed to build on the current evidence to determine how best to establish a collaborative partnership between families and health professionals and whether such a partnership improves treatment adherence, reduces intervention attrition and enhances pediatric weight management success.
Over the past 30 years, most developed and many developing nations have reported increases in the prevalence of pediatric obesity . Of particular concern are the short- and long-term physical and psychological health consequences that often accompany excess weight [2-4]. The refractory nature of obesity underscores the likelihood that health risks will persist across the lifespan [2, 4]. With these issues in mind, effective weight management care is needed to help obese boys and girls achieve improved health and wellness by establishing and maintaining healthy lifestyle behaviours [5, 6].
Current practices in pediatric weight management care acknowledge that the family environment has a strong influence on how children understand lifestyle behaviours. This environment is directly influenced by parental attitudes and behaviours regarding food availability and meal-time practices  as well as opportunities for physical activity [6, 7]. Parents serve a fundamental role in this regard; without supportive parental role modelling, it is challenging, if not impossible, for children to make sustainable lifestyle changes [6, 7]. For this reason, pediatric weight management care should include family-focused, lifestyle and behavioural interventions [8, 9]. Although the degree of parental involvement needed to achieve long-term weight management success is unclear from current literature, interventions that include both parents and children  or parents exclusively  appear to be superior to interventions that are designed for children exclusively .
A philosophy underpinning family-based pediatric weight management is that of family-centred care (FCC). 1FCC recognizes the family as a constant in a child's life and is defined in clinical care by mutually beneficial partnerships during care planning, delivery and evaluation  (see Table 1 for FCC principles). In FCC, health professionals adopt a consultative role with families to encourage their taking on an active and empowered role in their children's weight management . This approach represents an important shift from a historical paternalistic model of healthcare delivery [14, 15], but its implementation in pediatric weight management care remains ambiguous. Other models have been proposed that build on the concepts of FCC, such as the Collaborative Negotiation Model  and the Family-Collaborative Ecosystem Model (FEM) . Across all three models, it is evident that they promote collaborative partnerships and focus on overall health, both mental and physical. They also prominently feature families and parents as key stakeholders in health care. Although family–health professional relationships are impacted by structural (i.e. duration of appointments, healthcare insurance), professional (i.e. type of health professional and training) and contextual factors (i.e. family ethnicity or composition), to date, there has been little exploration of the nature and quality of this relationship between families and health professionals. This is a fundamental shortcoming since the therapeutic relationship between families and health professionals forms the foundation upon which care is delivered . With this limitation in mind, we examined the contemporary literature in pediatric weight management to identify characteristics that contribute to the family–health professional relationship and describe how these qualities can inform healthcare practices.
2. Honouring racial, ethnic, cultural and socioeconomic diversity and its effect on the family's experience and perception of care.
3. Recognizing and building on the strengths of each child and family, even in difficult and challenging situations.
4. Supporting and facilitating choice for the child and family about approaches to care and support.
5. Ensuring flexibility in organizational policies, procedures and provider practices so services can be tailored to the needs, beliefs and cultural values of each child and family.
6. Sharing honest and unbiased information with families on an ongoing basis and in ways they find useful and affirming.
7. Providing and/or ensuring formal and informal support for the child and parent(s) and/or guardian(s) during pregnancy, childbirth, infancy, childhood, adolescents and young adulthood.
Based on an adaptation of Whittemore and Knafl's procedure for conducting an integrative review , we undertook a review of the literature on family–health professional relationships. We defined family broadly, which allowed us to highlight its different functions, structures and dynamics. For the purpose of this research, the term health professional included physicians (general practitioners and specialists), registered nurses, registered dietitians and any other allied health professional (e.g. social work).
Inclusion criteria and search strategies
We included articles published in English, focused on clinical pediatric weight management, and contained information on the family–health professional relationship. This included articles that documented the experiences of health professionals delivering weight management care as well as studies investigating families' perceptions of the weight management care they received. No restrictions were set for article or study type, and the review could include empirical studies, theoretical models and polemic literature (opinion pieces). Any recommendations or guidelines related to pediatric weight management for health professionals that focused on developing a positive therapeutic relationship were also eligible for review inclusion. Publications were excluded from this review if they did not focus on families or if the content was related to other pediatric healthcare issues (i.e. eating disorders). Studies that focused on health professionals' barriers and attitudes related to providing weight management care were excluded if implications for family–health professional relationships were not discussed.
The literature search was conducted using medical search headings to locate articles indexed in the following three bibliographical databases: MEDLINE, PsycINFO and CINAHL from January 1980 to February 2010. A research librarian, with input from the team, developed a search strategy for each database. Search terms were comparable between databases and included overweight, obesity, pediatrics, child, cooperative behavior, therapeutic relationship, and family–professional relations (see Appendix 1 for example MEDLINE search strategy). Additional articles were also retrieved and reviewed using references lists from key articles that were identified through the electronic database search.
The following data were extracted and synthesized: author(s), year of publication, article classification, purpose, main findings and relevance to family–health professional relationships. Constant comparison analysis was used to identify outcome patterns and discrepancies between studies . Main findings were reduced to key ideas that related to family–health professional relationships and merged into broader themes. These themes served as a guide for organizing the findings and provided a framework to understand and present concepts regarding family–health professional relationships.
Our search strategy yielded 163 articles (Fig. 1). Of these articles, 24 met review inclusion criteria and were found to be diverse in methodological design: qualitative study (n = 9), cross-sectional survey (n = 1), comparative case study (n = 1), theoretical model (n = 2), literature review (n = 6) and column/editorial (n = 5). Two central issues relevant for family–health professional relations in pediatric weight management were identified across the articles: communication between health professionals and families, and healthcare delivery (Table 2). A summary of demographic and anthropometric characteristics of participants from 12 articles that reported these data is provided in Appendix 2.
Table 2. Broad themes and associated key ideas identified in data analysis
Communicating about weight
Parent and health professional (HP) perspectives on weight-related terminology
Verifying family understanding
HP having a non-judgmental attitude
HP avoiding negative relational elements (e.g. blame)
HP needing to be supportive, empathetic, diplomatic
Family experience with HP
Role of HP in initiating weight management counselling
Factors influencing decision of HP to initiate weight management discussions
Desired family support through referrals, assessments or clear advice
Goal-setting with family
HP role as facilitator
Long-term follow-up of family and continuity of care
Clinical intervention models
Communication about weight
Nineteen articles addressed health professional communication with families about weight management and underscored the important roles that language and terminology play in the health care delivery. In a survey of language preferences, Eneli and colleagues  found that when health professionals addressed weight-related issues in children, twice as many parents preferred the term gaining too much weight compared with the term overweight. Further, the authors reported that if parents perceived weight-related terms as hurtful or judgmental during healthcare communications, such perceptions negatively influenced even the most well-intentioned intervention. These findings were reinforced in two other studies [20, 21] in which parents expressed dislike of any weight-related terminology such as obesity and overweight. A qualitative study of nurses' communication with parents about children's weight showed that euphemisms were often used (i.e. large, heavy, big) rather than obesity to avoid offending families . Three other articles supported this study's findings [23-25] and suggested that health professionals use euphemisms or neutral words (rather than medical terms) to improve dialogue and minimize the likelihood of negative reactions by parents. Expert recommendations promote the use of medical terms for documentation and in professional-to-professional discourse, but when communicating with families, advise that health professionals replace emotionally laden words (i.e. obese, fat) with synonyms such as larger and bigger. Aside from avoiding language that may be viewed as potentially offensive, the use of technical jargon can also lead to misunderstandings . In a column addressing barriers to lifestyle changes among overweight youth, Ward-Begnoche and Thompson  encouraged health professionals to ask families to repeat (in their own words) what they heard the health professional say rather than assuming the information they provided was clearly understood.
The importance of health professionals remaining non-judgmental during weight-related discussions with families was emphasized across multiple publications [5, 23, 25, 27]. Central to these articles was the need for health professionals to avoid blame, guilt and stigmatization during family discussions [24, 25, 28, 29] and to focus on being supportive, empathic, diplomatic and keeping children's best interests in mind [5, 22, 30]. However, studies that explored parents' weight management care experiences for their children revealed negative encounters with health professionals. In a qualitative study of parents' perceptions of help-seeking experiences , mothers reported feeling blamed for their sons' or daughters' weight, feeling dismissed as an overanxious parent and receiving no advice for making healthy lifestyle changes. Similarly, Holt et al.,  reported that some parents found health professionals to be rude and judgmental and that their children were often ignored or minimally engaged during clinical encounters. A study of Latino carers' experiences with weight management  described health professionals as disrespectful and not listening to parents' concerns. Moreover, the authors reported that carers felt marginalized by staff who did not speak Spanish and wanted written weight management instructions in their mother tongue. An exception to these reports was documented by Pagnini and colleagues , who found that although weight was a sensitive issue to discuss, parents in the study did not report any negative interactions with health professionals.
The discrepancy between parental expectations of health professionals and health professionals' approaches to FCC has been described in the literature. In a qualitative study of parents' attitudes towards the role of physicians in weight management care , parents expected their physicians to initiate discussions about their children's weight if it was a health problem, even if concerns about weight were not the primary reason for the clinical appointment. Health professionals, on the other hand, have reported reluctance in raising weight-related issues with families . The decision by health professionals to discuss obesity with families depended on whether concerns about weight prompted the visit  and whether health professionals already had an established relationship with the family [22, 30, 34]. General practitioners and nurses have expressed hesitancy in addressing weight with families out of fear of jeopardizing the relationship and eroding trust [22, 24, 34, 35]. One study reported that when health professionals raised weight as an issue, it was often linked to another health concern (e.g. asthma) with weight management care offered as a possible solution . This type of lateral approach to care has also been discussed by Scott and colleagues , who concluded that the lack of pediatric weight management counselling is likely the result of health professionals feeling uncomfortable with initiating weight-related discussions with families.
Health care delivery
Behavioural strategies in weight management were described in 12 articles that promoted collaborative family–health professional relationships consistent with FCC. The majority of these articles were opinion-based with few derived from empirical research. Studies exploring parental expectations and articles providing weight management recommendations have suggested health professionals should offer support through assessments such as blood tests, making referrals to other health professional specialists (when indicated) and/or providing clear and practical advice depending on families' needs [23, 24, 29, 31, 33, 37]. Families and health professionals were also encouraged to work together to establish realistic lifestyle and behavioural goals for weight management [5, 23, 26, 27, 37]. When families encounter challenges, health professionals were encouraged to adopt the role of facilitator to assist families with problem-solving and develop potential solutions [23, 26, 27, 38]. Continuity of care and long-term support and monitoring of families were recommended as essential elements of pediatric weight management care [5, 23, 26, 38] to ensure that healthcare delivery considers families' needs and accounts for cultural considerations and preferences.
Two clinical models for pediatric weight management were identified in our review that focused on developing collaborative practices between families and health professionals as well as integrating lifestyle and behavioural strategies [16, 17]. There was agreement that a safe, trusting environment, one that is supportive and non-judgemental, was essential for health professionals to work effectively with families and that communication formed the foundation for effective collaboration. Tyler and Horner  described a family-centred, collaborative negotiation model for addressing health risks in overweight and obese children. The model is composed of the following three components: the child health profile, the collaborative negotiation process, which is a combination of motivational interviewing and Touchpoints (an approach to enhance parental competence and build strong parent–child relationships from birth to early childhood) , and lifestyle-related health indicators (i.e. eating behaviours). The goal of the model is to increase family participation in care by incorporating family feedback throughout the care process. The model has been piloted with low-income families; preliminary results emphasized how families can enhance their level of participation by taking ownership of the ideas and strategies offered in their interactions with health professionals .
A second model is the FEM by Goetz and Caron , which incorporates family systems theory, ecosystems theory and biopsychosocial theory with Eastern and Western philosophies of health. The FEM model focuses on balance and harmony; a new state of health is expected to emerge as the partnership evolves between the patient and health professional. FEM emphasizes patients' strengths rather than the disease. Akin to the model by Tyler and Horner , FEM begins by setting goals that have been negotiated between partners, followed by identifying potential obstacles and available resources for support. This process leads to customized care strategies for the family. To optimize health outcomes, the partnership addressed the variety of contextual factors that impact health . Our review did not identify any evaluations of this model.
This integrative review of family–health professional relations in pediatric weight management highlighted how clinical approaches can impede positive weight management care experiences and limit collaboration between parents and health professionals. Negative experiences with weight management care described by parents often resulted from paternalistic attitudes and behaviours of health professionals with insufficient consideration given to family participation during clinical encounters. These findings provide a basis for future research directions and clinically oriented recommendations that can improve our understanding of family–health professional communication and ensure that FCC underlies clinical interactions.
Although clinical guidelines for obesity management promote the importance of respectful and collaborative partnerships between families and health professionals [5, 24, 26, 30], these recommendations do not mirror families' experiences. We found that many families perceived health professionals' language and terminology to be offensive or overly technical and that parents reported feeling blamed, judged and guilty for their children's obesity. In addition, when health professionals were unable to communicate with families in their preferred language, this led to families feeling marginalized. All of these feelings can undermine trust and respect as well as inhibit collaboration. Active family participation is central to FCC so activities that encourage health professionals and families to communicate and work together on evidence-based weight management activities such as goal-setting and monitoring lifestyle behaviours [5, 23, 26, 27, 37, 38] enable collaboration and promote healthy lifestyle and behaviour changes. Communicating health information to families in an unbiased (neutral) and accessible manner will help health professionals to connect with families . Although several studies have shown that this type of communication can be difficult to achieve [19-22], effective communication is essential to FCC. Health professionals should also be mindful of the different roles and levels of involvement that parents want, need or are able to accept in the weight management process. The reality that roles and levels of involvement are dynamic and likely to vary over time is a reflection of the real-world environment so health professionals should strive to be responsive, flexible and nimble in their work with families.
Although this review showed that many parents perceived weight-related terminology as offensive, different findings have been reported in adults. For example, Tailor and Ogden  explored terminology preferences with health professionals and adult patients; the former preferred the use of euphemisms whereas, regardless of their body mass index, the latter had a strong emotional response to the euphemisms and perceived their excess weight to be more life-threatening and urgent to resolve. Interestingly, use of the word obese did not seem to influence the level of trust patients had with their health professional . The different reactions reported between parents of obese children and obese adults may be related to the care-giving role of parents who are responsible for their children's health and well-being and who may perceive their children's obesity as a poor reflection of their parenting. Results from the 12 empirical studies in this review suggested that parents were also concerned about weight-related stigma  and that words such as obese stereotyped their children . Euphemisms such as heavy or gaining too much weight refer to a process rather than a label; framing obesity in this light also implies that it can be reversed . Given the possibility that families will respond differently to weight-related terms, health professionals should work with families to develop a shared language and understanding , which is consistent with FCC and helps to foster a collaborative spirit. It is likely that framing conversations around health or using euphemisms (i.e. unhealthy weight, heavy) rather than obesity may improve families' receptivity to and health professionals' degree of comfort with talking about weight-related issues .
Several studies in this review described the high value that parents placed on health professionals' demonstrations of empathy and concern for their health [5, 22, 30]. These findings are noteworthy when accounting for the importance of affective behaviours in healthcare relations since interpersonal sensitivity by health professionals enhances families' satisfaction with the care they receive [44, 45]. Health professionals who are perceived as being warm, affirming, understanding, responsive, sensitive and approachable are likely to develop higher degrees of rapport with patients . According to Hall and colleagues , rapport is dyadic, includes elements such as shared positive feelings and coordination between partners and contributes to a positive family–health professional relationship because it facilitates communication and increases the ease with which families share information [42, 47]. Rapport also promotes the view of the family as a constant in the child's life [13, 48], and consistent with FCC, regards parents as contributors of cultural considerations and values [44, 49] that are necessary for the planning of clinical care goals and carrying out a weight management plan . We recommend that health professionals remain sensitive to families' preferences within clinical interactions (i.e. in what language does the family prefer to communicate? Will an interpreter be required? What family members should be included in the discussion?). For health professionals wanting to optimize their work with families, candid feedback can be retrieved from families about their clinical experiences to identify any negative attitudes or behaviours that families perceive but may go undetected by health professionals. Engaging in this type of reflective practice may reveal unintended (and unflattering) findings about health professionals' interactions with families, but this process offers an opportunity for professional growth and development that can heighten awareness of possible biases. Longitudinal research is needed to identify whether constructs such as health professionals' degree of empathy, concern or responsiveness predict successful weight management outcomes for families or whether families' experiences (positive or negative) impacted their decisions to access healthcare services in the future. Although health professionals are generally aware of the importance of how information is communicated to families, their degree of self-awareness is not known. A content analysis that includes what health professionals actually say and do during clinical interactions could be triangulated with families' and health professionals' perceptions of communication to contribute some objectivity and insight in this area.
The negative attitudes of health professionals identified by parents highlight the potential role of weight-related biases influencing attitudes and behaviours during family interactions. To our knowledge, no pediatric studies have examined obesity bias in weight management, but several adult studies have reported that health professionals have implicit and explicit anti-fat attitudes [50, 51]. These attitudes may compromise health services delivery due to preconceived notions about patients and the cause(s) of their obesity. The need to explore this issue in pediatric weight management is critical given the implications that weight-related bias can have for FCC, especially with respect to rapport building and maximizing treatment adherence [52, 53]. Studies to characterize the presence of weight-related bias in pediatric weight management, its magnitude across disciplines (i.e. medicine, nursing, dietetics, psychology) and the impact it has on healthcare delivery remain outstanding avenues of research that can inform the field.
Adherence refers to the degree to which clinical care recommendations are followed , which is highly relevant to the field of pediatric obesity given its chronicity and the lifestyle and behavioural changes required for successful, long-term weight management. Reports from other areas of pediatric health care have offered important insights into this construct. For instance, Drotar  showed that parents of children with chronic illnesses (i.e. asthma, diabetes, cancer) who were dissatisfied with physician communication and support were less likely to adhere to treatment recommendations. A review by DiMatteo  on communication and treatment adherence showed that families were less likely to share their difficulties with health professionals and adhere to treatment plans when they believed they would be judged or unsupported. In addition, patients who were adherent were three times more likely to have a positive outcome than those who were not adherent. Although none of the studies in our review explicitly evaluated the influence that the family–health professional relationship had on adherence to clinical recommendations, a better understanding of this issue in the field of pediatric weight management may yield important insights. Research is needed to determine the individual (i.e. self-efficacy, cognitive development), family (i.e. degree of social support from siblings and/or extended family members) and environmental (i.e. socioeconomic status) factors that mediate or moderate whether clinical recommendations are followed since adherence to behaviour changes can improve treatment outcomes in pediatric weight management .
We found that most health professionals were unlikely to initiate discussions about obesity with families, while many families reported relying on health professionals to take the lead in initiating these discussions. Research examining well-child visits has shown that obese children do not usually undergo health screening or receive counselling. O'Brien and colleagues  found that only one-half of obese children (according to objective criteria) were identified as such by health professionals. In another study, only 8% of overweight children received weight management counselling during their clinical visit to a family practice . While a lack of weight management counselling may stem from the lack of knowledge and competence of health professionals, it may also be impacted by broader determinants. Frequently cited factors have included a lack of formal training [35, 58, 59], scarce resources and support services for families [35, 59], inadequate reimbursement for weight management counselling  and insufficient time during clinical appointments [35, 59, 60]. The emergence of pediatric obesity as an urgent health issue suggests that health services should be reoriented to minimize potential barriers in order to provide the most efficient and effective care possible, which are likely to vary internationally. In countries that provide access to universal health care, financial reimbursement for clinical services and limited time availability for clinical appointments may be less important factors than in other countries that deliver weight management services through for-profit health maintenance organizations. How these factors influence FCC and the quality of family–health professional relations remains to be clarified. National/international comparisons between different healthcare systems or weight management services (i.e. primary care vs. tertiary care; publicly vs. privately funded health care) would reveal whether any macro-level factors (i.e. reimbursement, time constraints, degree of institutional support) influence, either positively or negatively, outcomes such as collaboration and FCC. From educational and clinical perspectives, there remains a clear need to augment curricula for trainees in the health professionals with evidence-based information (philosophical, conceptual and practical) related to obesity and weight management; offering continuing education opportunities and resource toolkits [61, 62] for practicing health professionals would serve to improve knowledge and competence in pediatric weight management as well. Although not informed directly by our review, improving health professionals' ability to address pediatric obesity may be most important for families who access health services infrequently due to limited resources or who are at highest risk for obesity and obesity-related comorbidities. Expert guidelines  recommend measuring and weighing children during all well-child visits so obesity screening, prevention and management will be more commonplace, regardless of how regular or sporadic the clinical encounters may be. Further, techniques such as motivational interviewing  and cognitive behavioural therapy  include elements of collaboration and FCC and are well-suited for pediatric weight management care. An advantage of these clinical approaches is their allowance for customization of care to families' degree of readiness to change as well as building on family-specific needs, capacities, and strengths. It also helps families to understand how their lifestyle impacts their weight and health.
It is important to acknowledge the limitations of this review. Because less than half of the publications that met our inclusion criteria were empirically based, the lack of generalizability from this body of research is a drawback. Clinical interventions and other longitudinal study designs, examples of which are described earlier, are needed to build on these findings, which are primarily descriptive in nature. Reports characterizing the prevalence of obesity have shown that some groups are at increased risk for, or disproportionately affected by, obesity . It is unclear from our findings whether techniques to enhance FCC and collaboration differentially impact (positively or negatively) one group over another so our recommendations must be tempered given this lack of specificity. In addition, the two theoretical models we reviewed [16, 17] have yet to be comprehensively evaluated so while they have the potential to inform clinical practice, there is no way to determine the utility and generalizability of these models at this point. Rigorous evaluations of these models are required.
In summary, this integrative review highlights the importance of family–health professional relationships for pediatric weight management. Our observations revealed that communication, health professionals' behaviours and families' perceptions of the care received had a profound impact on the relationships created between families and health professionals. Of particular relevance is that a positive relationship was characterized by sensitivity, honesty, trust and respect. Health professionals are encouraged to work collaboratively with families to optimize weight management in a manner consistent with the philosophy of FCC, which will serve to enhance families' active participation in their care.
Conflict of Interest Statement
The authors have no conflicts of interest to declare.
This research was funded, in part, through a grant from the Stollery Children's Hospital Foundation (Edmonton, AB) and the Women and Children's Health Research Institute (Edmonton, AB). Biagina- Carla Farnesi was supported by scholarships from the Department of Pediatrics, Faculty of Medicine and Dentistry at the University of Alberta and the Government of Alberta. Geoff DC Ball was supported by a Population Health Investigator Award from Alberta Innovates – Health Solutions and a New Investigator Award from the Canadian Institutes of Health Research. Amanda Shantell Newton was supported by a salary support award from the Canadian Child Health Clinician Scientist Program in partnership with the SickKids Foundation, Child & Family Research Institute (British Columbia), Women & Children's Health Research Institute (Alberta), Manitoba Institute of Child Health. The authors wish to thank Ms Linda Slater for providing assistance with our literature search.
Appendix 1 Sample MEDLINE search strategy
Corresponding MeSH term
1 326 713
1 AND 2
3 OR 4 OR 5 OR 6
7 AND 8
(7 AND 8) limit 1980 to Current
Appendix 2 Demographic and anthropometric characteristics of parents/caregivers, children and health professionals from the empirical studies (n = 12) included in this review
1. Studies involving parents/caregivers and children (n = 8)