Composición química en la zona de agrietamiento

Van Gerwen et al., (2009) systematic review identified low levels of knowledge of primary care physicians about appropriate treatment and management regimes and a particularly low reported use of guidelines (Kolagotla and Adams, 2004). The review also found low levels of self-perceived competency to treat childhood obesity, (Price et al., 1989; Jelalian et al., 2003) and lack of clinical consensus around treatment. However, Sivertsen et al., (2008) study of GPs in South West Sydney challenged the view that reported use of guidelines equated to a lack of GP interest and found that although clinical practice guidelines adherence was far from universal, the GPs in this study were motivated and aware of the importance of managing childhood obesity.

Mazur et al., (2013) compared the attitudes, skills, and practices in childhood obesity management of primary health care providers from France, Italy, Poland, and Ukraine. Postal questionnaire was returned by 1119 participants, which had a limited response rate of 32.4%. The study revealed that most of the primary health care practitioners were aware of their

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critical role in obesity management but did not feel sufficiently competent to perform this effectively. The adherence to recommended practices such as routine weight and height measurements, BMI calculation, and plotting growth parameters on recommended growth charts was also poor. Most primary health care practitioners in this review recognised the need for continuing professional education in obesity management, stressing the importance of appropriate dietary counselling. The authors concluded that the critical problem is not elaboration of guidelines, but rather creating support systems for implementation of the medical standards among primary health care practitioners.

Lachal et al., (2013) highlighted that most GPs, when managing a child who is obese in a primary care setting, tend to focus on nutritional and dietary advice (Holt et al., 2011) and the need for more exercise and less sedentary activities. Walker et al., (2007) extended this conclusion by reporting that whilst the GPs framed their interventions in terms of providing dietary and exercise advice, these were often felt to be ineffective, with a feeling of doubt that the advice would have limited impact upon the child's weight given the families’ current eating patterns. This pessimism was reflected in one of the quotes from a respondent,

“We talked about ‘five a day’ but this kid didn't eat five a week. Sunday lunch was the only time they ate vegetables. I have no great expectations that this kid will come back walking to school, eating ‘five a day’, and have lost any weight. I have very little faith.” (Walker et al., 2007, p.5).

Turner et al., (2009) added a further perspective on the reluctance of the GPs in their study to sometimes offer little more than basic dietary advice, based on a view that parents may be unable to prepare healthy meals due to a lack of knowledge, money, or time. Again a quote from one of the participants reinforces the challenge that some of the parents felt, “around here, to eat good food is expensive, finding the money to pay the rent is more immediate than whether they are getting the best fresh fruit and vegetables that they and their children need,”

(Turner et al., 2009, p. 860).

In addition, Turner et al., (2009) also found that some GPs in their study did not have the expertise or time to manage childhood obesity, and indicated that their concern that they had no effective treatment to offer, often affected their motivation to become further engaged in this area. When children did lose weight, they tended to think that they played little role in it, often attributing this to physiological changes such as growth spurts.

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A further role presented in the literature related to the role of GPs in recruiting families to join weight management programmes. The recently publicised NICE guideline 47 (2013) on weight management interventions for obese and overweight children, highlights the key role of health professionals in referring children and families to community or clinic based weight management interventions. However the literature suggests that whilst both programme users and providers felt GPs should raise awareness, or refer children to lifestyle weight management programmes, there was an acknowledgment that this recommendation was rarely being sufficiently implemented, (Stewart et al., 2008; Watson et al., 2011). Other studies have also described circumstances in which children were not referred by GPs, or inappropriate referrals were made to such services, (Wolman et al., 2008; Woolford et al., 2010; Jinks et al., 2013).

Finally, the research literature has also identified that the perceptions of health professionals regarding childhood obesity treatment appear to be different than that of parents. Research by Staniford et al., (2011) of both parents and health care professionals, (which included GPs) found an agreement that treatment should be family based, incorporating physical activity, nutrition and psychological components, and should be delivered in local environments that are familiar to the recipients. However, there was incongruence between stakeholders towards the sustainability of obesity treatment interventions. For example, parents and children reported needing on-going support to sustain behavioural changes made during treatment, while health professionals suggested interventions should aim to create autonomous individuals who exit treatment and independently sustain behaviour change. Staniford et al., (2011) concluded that interventions need to incorporate strategies that promote autonomous and self-regulated motivation, to enhance families’ confidence in sustaining behaviour change independent of health professional support.

Stewart et al., (2008) also highlighted the differences in opinions regarding treatment outcomes between parents and their doctors. For GPs the outcomes such as weight loss and improvement in BMI scores were of fundamental importance in the treatment of childhood obesity. However, for the parents interviewed in this study, weight and BMI were not a priority at the end of treatment; rather their prime desired outcomes were improvements regarding their child’s self-esteem and quality of life. Further research has indicated that when families accept their child’s weight status and are motivated to engage their children on a treatment programme, they have a number of outcomes they wish to achieve. For example, both the UK and international literature indicate that psychological wellbeing and improving

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children’s confidence and self-esteem appears to be highly valued among both children, (Holt et al., 2005; Murtagh et al., 2006; Morinder et al.,2011) and their families (Dixey et al., 2006; Stewart et al., 2008; Pescud et al., 2010; Twiddy et al., 2012). Stewart et al., (2008) suggested that the perceived benefits to children’s self-esteem or quality of life were consistently more important than weight outcomes for parents. In addition the ambition to improve children’s social integration, to make friends, or reduce bullying has been reported as key incentives to joining weight management programmes (Murtagh et al., 2006; Alm et al., 2008; Twiddy et al., 2012). Finally, improving the current health of the child and preventing future health problems were also described by parents and children as incentives to joining weight management programmes (Dixey et al., 2006; Alm et al., 2008; Watson et al., 2011; Jinks et al., 2013). It is perhaps inevitable that this lack of concordance on outcome measures between the priorities of the family and those of the GPs would lead to some frustrations from both parties, and provides challenges for commissioners and providers of weight management programmes.