Provider Observations of Youth with Early Onset Severe Obesity in Tertiary Care Obesity Programs

Abstract

Background:

Over 2% of children between the ages of 2 and 5 have severe obesity; however, little is known about the characteristics of this population to guide healthcare professionals in providing care. An initial step is to examine observations of practitioners who manage children with severe early onset obesity in the clinical setting.

Methods:

A total of 72 interdisciplinary healthcare providers with experience providing obesity treatment to children under age 5 with severe obesity completed a semistructured online questionnaire. Participants responded to 10 open-ended questions about provider observations on several topics, including nutrition, eating behavior, activity, family structure and history, medical history, psychological conditions, and household routines. Data analysis was conducted using grounded theory methods. Emerging themes and subthemes were analyzed based on topics and provider discipline (e.g., medical, nursing, and psychology).

Results:

The most commonly observed and reported characteristic of young children with severe obesity was a parent-described dysfunctional approach to food, including frequent complaints about hunger, food seeking, and lack of satiety. Other characteristics included the presence of externalizing behaviors in the child such as temper tantrums and ADHD, developmental delays, medical comorbidities (e.g., asthma and sleep apnea), and unstructured home environments.

Conclusions:

Drawing on the experience of an interdisciplinary group of healthcare providers, this is the first study to describe provider observations of the young child with severe early onset obesity. If validated, these observations can serve to illuminate areas for further education and inform potential clinical subtyping, providing an opportunity to identify target areas for intervention.

Introduction

Severe obesity is currently defined as a body–mass index (BMI) greater than 120% of the 95th percentile for children aged 2–18 years,¹ and there is no consistent definition for children under the age of 2.^2,3 In 2016, the prevalence of severe obesity among children aged 2–5 years was 2.1%, with a significant increase in rates between 1999 and 2016.^4,5 Lifestyle risk behaviors and inappropriate weight gain, which begin in early years, often persist into adolescence and adulthood with increased risk for serious comorbidities.^4–6 While it is clearly important to address obesity in young children, severe obesity at young ages is a strong predictor of persistence into adulthood and obesity-related morbidity in childhood.^7,8

With discouraging outcomes of traditional lifestyle interventions for individuals with severe obesity and inadequate access for intensive treatments or bariatric surgery,^1,9 early childhood may offer a critical period for treatment with a high likelihood of success as risk behaviors are less likely to be entrenched. How providers perceive characteristics of this group of children may provide useful insight on understanding approaches for effective treatment options. Provider perceptions may also illuminate treatment targets as well as barriers to successful treatment implementation.

There is a large volume of research describing characteristics of children and adolescents with excess weight, with data often obtained from the youth or parent.^10–13 Obesity treatment involves shared decision-making and an interplay between providers, patients, and families, especially for young children. The observations that children, families, and providers bring to these interactions play an important role in the family's engagement, effectiveness of treatment, and satisfaction with care. For example, the positive outlier theoretical approach has allowed an examination of child and parent perspectives of helpful weight management strategies used by a subset of families with children who successfully reduced their BMI.^14–16

Provider observations of young children with severe obesity can also serve as a means to improve understanding, but have yet to be investigated. As with the wealth of knowledge we have gleaned from patient and parent observations and perceptions around treatment, obtaining a better understanding of providers' observations can help with generating ideas about ways to improve training of providers in obesity treatment especially for the young child with severe obesity. Providers often feel poorly equipped to work with youth and families with obesity and desire additional training in behavior management, parenting techniques, and how to address family conflict.¹⁷

Although there are not many studies that specifically look at provider observations or perspectives independent of patients and families, they do exist.^15,16 One such qualitative study examined pediatric primary care providers' perceptions of barriers to adolescents seeking treatment for depression and the findings led to generation of patient-centric ideas for intervention development.¹⁸ A second study assessed primary care providers' perspectives about somatic symptom and related disorders (SSRDs).¹⁹ The study identified potential opportunities for provider training in communication, evaluation, and management of SSRDs in pediatric patients. While provider perspectives are not widely explored, these two studies demonstrate generation of ideas for intervention targets and provider training opportunities.^18,19

This qualitative study using a semistructured open-ended survey is unique by seeking to gain insight from healthcare providers on several disciplines about young children with severe obesity. A semistructured, open-ended qualitative tool was completed by an interdisciplinary group of pediatric providers in tertiary care obesity treatment programs. While provider observations about the young child with early onset obesity cannot be categorized as actual dietary and behavioral habits of the child or family, they provide insight on what families relate to their provider, what providers observe during their interaction with the child and family, and how providers can use that information for diagnosis and treatment.

This article presents unique provider observations based on their encounters with young children with severe obesity and their families. These observations are an invaluable first step toward identifying common themes from providers, which may drive treatment and inform improvements in provider training for working with young children with severe obesity and their families.

Methods

Sample Instrument

In 2014, the American Academy of Pediatrics Institute for Healthy Childhood Weight (IHCW) and the Children's Hospital Association (CHA) convened the Expert Exchange (EE), an interdisciplinary team of 40 participants from tertiary care obesity programs at 21 children's hospitals across the United States. The EE has been described by Tester et al.²⁰ One of the aims of the EE was to characterize severe obesity in children 5 years and younger. No known studies have attempted to describe the clinical perceptions of providers about this population of vulnerable children. As such, a subgroup of the EE developed a survey to assess these clinical perceptions as a first step in characterizing physical and behavioral features of this population relevant for designing potential clinical interventions.

Before administration of the survey, the entire EE group reviewed the survey questions and provided feedback. In October 2014, the CHA invited participants in the EE to complete an anonymous online survey, administered through the Survey Monkey website, to assess provider observations of the characteristics of children 5 years and younger with severe obesity.

The survey was designed for this study and has not been used elsewhere. Information on professional discipline, years in practice, and experience working with children 5 years and younger with severe obesity was collected. The survey included 10 open-ended questions on nutrition, eating behavior, activity, family structure and history, medical history, psychological conditions, and household routines, as well as two closed-ended questions related to developmental delay and medication use (Table 1). The topics were selected based on extant literature on risk factors for obesity/severe obesity in the young child.^4–6

Table 1.

Online Survey Questions

Question 1	When I see children who are aged 5 and younger with severe obesity, they seem to exhibit behavioral characteristics such as ____________________
Question 2	Do these children typically have a developmental delay?
Question 3	When I see children who are aged 5 and younger with severe obesity, they seem to approach or relate to food __________
Question 4	When I see children who are aged 5 and younger with severe obesity, their household routine (sleep hygiene, meal patterns, and playtime, etc) seems to be ____________
Question 5	When I see children who are aged 5 and younger with severe obesity, their family structure (use your interpretation, but describe in text) seems to be ___________
Question 6	When I see children who are aged 5 and younger with severe obesity, their parent(s) seem to be ______
Question 7	When I see children aged 5 and younger with severe obesity, their parents identify the risk factors for the excess weight as _______
Question 8	When I see children who are aged 5 and younger with severe obesity, their physical activity tends to be ________
Question 9	When I see children who are aged 5 and younger with severe obesity, they seem to have associated medical problems such as ________
Question 10	When I see children who are aged 5 and younger with severe obesity, they seem to have associated psychological conditions such as _______
Question 11	Do these children typically have a history of medication use?
Question 12	When I see children who are aged 5 and younger, I notice other characteristics such as ________

Practitioners recused themselves from completing the instrument (13%) if they did not have any experience with children 5 years and younger with severe obesity. To broaden the sample and reduce any potential bias associated with gathering responses from only EE participants, a group that had worked together on the topic for at least 1 year, the anonymous online instrument was also sent to 2013 Children's Hospital Association Obesity Survey respondents²¹ who were asked to share the instrument broadly with their teams. Similar to EE participants, these respondents are providers in tertiary care obesity treatment programs at children's hospitals and will be referred to in the results as other hospitals (OH).

The CHA collected and deidentified all data from the survey before sending them to the authors for analysis. The sample size was deemed appropriate given that thematic saturation (i.e., lack of any new themes) was achieved for all 12 questions.

Data Analysis

Secondary analysis of deidentified data was conducted using grounded theory methods.²² NVivo 10 software was used to assist with organizing the coding. All participant responses were read line by line to establish topic codes and key phrases. All topics and key phrases were included in a coding guide developed by the lead author (B.J.G.). Themes were then developed based on topic codes and revised using an iterative process as patterns became more apparent, resulting in saturation of themes.

The responses for the 10 open-ended questions were each independently reviewed and coded by three raters from different disciplines (e.g., clinical psychology, nursing, and public health) to identify themes and subthemes from each respondent using the coding guide. This investigator triangulation helped ensure credible and nonbiased results.²³ Inter-rater reliability calculated as number of agreements/(number of agreements + number of disagreements) was high for all questions (above 92%).²⁴ A fourth rater adjudicated any coding differences (B.J.G.). The results below are based on the consensus of codes. Responses to questions were comparable between the EE and OH groups. Thus, responses on topics were pooled and results presented in aggregate form.

Table 2 shows the number of providers by discipline, and average years of experience for each discipline and combined average years of experience for all providers in each group (EE and OH) were calculated. Illustrative quotes were taken from their original context from the survey and clustered by emerging themes. The study was reviewed and deemed exempt by the Nationwide Children's Hospital Institutional Review Board.

Table 2.

Characteristics of Respondents

Characteristics	Expert exchange (EE)	Other hospitals (OH)	Total sample
Professional discipline–number of respondents
Physician	22	13	35
Registered Dietitian	4	11	15
Psychologist	8	3	11
Nurse Practitioner	2	5	7
Social Worker	—	2	2
Exercise Physiologist	—	2	2
Average number of years of experience providing care to children 5 years and younger with severe obesity
Physician	10.4 years	10.4 years	10.4 years
Registered Dietitian	7.0 years	5.1 years	5.5 years
Psychologist	8.8 years	2.0 years	7.1 years
Nurse Practitioner	8.0 years	7.0 years	7.2 years
Social Worker	—	1.5 years	1.5 years
Exercise Physiologist	—	2.0 years	2.0 years

Results

A total of 36 providers from children's hospitals participating in the Expert Exchange and 36 providers who had participated in the 2013 CHA Obesity Survey completed the online instrument.

Participant characteristics are described in Table 2. Some differences emerged with the composition of providers responding to the open-ended instrument for the EE versus OH groups. Specifically, the EE group had a greater percentage of respondents who were physicians and psychologists, whereas the OH group had more registered dietitians. Average years of experience providing care to young children with severe obesity were similar for physicians in both groups. For other providers such as registered dietitians, psychologists, and nurse practitioners, the number of years of experience was slightly higher in the EE group with the most notable difference for psychologists (EE = 8.8 years vs. OH = 2.0 years).

Analyses of provider responses to the 10 open-ended questions revealed two main themes: perceptions of frequently occurring child characteristics and perceptions of common parent/family characteristics. Each major theme had multiple associated subthemes (Table 3).

Table 3.

Summary of Provider Observations: Major Themes and Subthemes

Frequently occurring child characteristics

Dysfunctional approach to food

Presence of externalizing behaviors (e.g., tantrums, ADHD)

Low levels of physical activity

Presence of medical conditions (e.g., asthma, OSA)

Frequently occurring parent/family characteristics

Inadequate parenting skills

Less structured home environments

Genetics

OSA, obstructive sleep apnea.

Provider Observations of Child Characteristics

Providers noted that when young children with severe obesity present for care, they were often described by their parents as having a dysfunctional approach to food. Providers termed this approach as an increased interest and preoccupation about food, lack of satiety, and regular engagement in food-seeking behaviors. There was general agreement among physicians, registered dietitians, and psychologists on food-seeking behavior and lack of satiety; less than 50% of nurse practitioners and physical therapists endorsed these behaviors. Common responses by providers describing this characteristic include:

“They are preoccupied with food - thinking about and asking for food from the time they wake up in the morning until when they go to bed at night.”

“Sometimes food can be: a reward for good behavior, a way to quiet them, a way to get attention from a parent or adult, can be soothing.”

“Frequents complaints of feeling hunger; heightened interest in seeking food; frequent requests for having more to eat and snacks/meals and when not given, will often result in persistent demands, that at times may result in tantrums; this behavior is often reinforced my parents when they “give in” to these demands to prevent the child from acting out.”

“Strong food seeking behavior. Insatiable appetites. Crying or temper tantrums around food.”

Often in conjunction with a dysfunctional approach to food, providers also commented on parents describing general behavioral problems and ADHD. ADHD was endorsed by all provider types, while only physicians and registered dietitians endorsed emotional dysregulation. Examples of provider responses include:

“Many seem to have underlying psychological symptoms but really much of this stems from dysregulation. ADHD does seem to be a common condition in this population.”

“Strong temperaments and behavioral issues.”

Providers described young children with severe obesity as generally having low activity levels, although some noted that a subset of parents consider their children quite active, as seen in the following provider observations. All provider types endorsed the perception that parents often reported low physical activity.

“Either they are very active and parents wonder how they have become obese, or pretty inactive, preferring mostly sedentary activities.”

“In the majority of cases, the physical activity is low. However, a significant minority of these children do have normal or even high levels of physical activity (and in many of these cases, this is structured and documented PA, not just parental report that the child is “very active”).”

A range of medical problems were also reported by providers, such as asthma, sleep difficulties/obstructive sleep apnea, insulin resistance, and abnormal lipids. Asthma medications were commonly used by patients. Sample provider responses include:

“[They seem to have associated medical conditions such as] asthma, insulin resistance, sleep apnea, leg, and feet pain.”

“The most common comorbidities are asthma and obstructive sleep apnea (OSA). OSA is often undiagnosed, and may be severe. Medical providers should be alert to this possibility and routinely screen for symptoms (loud consistent snoring, observed apneas or “gasping”, nocturnal enuresis for those who were previously dry at night). Behavioral issues in school are also common, and may be a consequence of the OSA. Other than these issues, most of these children are quite healthy; most of the medical consequences of obesity have not yet developed.”

Provider Observations of Parent and Family Characteristics

Providers described parents of young children with severe obesity as reporting difficulty in implementing parenting skills, especially limit setting, feeling overwhelmed/stressed, having less structured home environments, and inconsistent routines. All provider groups often endorsed lack of structure/disorganized home environment. All provider types also described single-parent households, caregiver challenges associated with stress and financial difficulties, and that grandparents were often involved with caregiving. Provider examples include:

“Powerless. Often they seem completely unable to say no to their child because they don't want to deal with the behavior or don't want to fight about food.”

“Stressed, lacking education about appropriate behavioral techniques and normative behavior.”

“Disorganized; often sleep hygiene is a huge issue and there is a lot of grazing which is not controlled.”

“The families of such children are often relatively disorganized, with little structure for timing of meals or snacks, and also little structure for other activities.”

Providers were asked to report on what parents typically report as the risk factors for their child's excess weight. Providers frequently mentioned parent reports of poor satiety/complaints of always feeling hungry and genetic factors. None of the registered dietitians, psychologists, or physical therapists endorsed diet content as a risk factor. Typical provider responses include:

“(1) Family history: We were all “this big” and grew out of it (2) Traumatic events (3) Grandparents or other caretakers who over and frequently feed (4) Naturally food seeking without the sense of satiety… “She has always been a hungry baby. I could not feed her enough”.”

“Parents often able to identify a genetic predisposition (“easy gaining” runs in the family). In addition, many parents identify snacking patterns, excessive TV/video game viewing, as contributors to obesity. In many cases, the parents say that the child has a strong appetite and is “never full”.”

Discussion

Very little is known about the characteristics of the young child with severe early onset obesity. The results of this qualitative instrument represent an attempt to describe provider observations of children with severe obesity seen in tertiary care obesity treatment programs. Providers across different disciplines were very consistent in their descriptions of children and families, as reflected in the themes that emerged. The themes and subthemes are consistent with extant research on young children with severe obesity.^25,26

Obtaining qualitative information on how the treating provider perceives the concerns raised by the family is important for several reasons. First, it provides more contextual depth to risk factors and personalizes how typical lifestyle risk factors are relevant to young children with severe obesity. This information when understood is often the initial step when considering how to construct an effective health risk message and whether a family is likely to perceive the message as efficacious in addressing their child's weight problem.

An important and significant theme that emerged across disciplines and topics was providers reporting that parents often felt overwhelmed, stressed, and powerless to address the problem. Future interventions will need to focus on mastery of parental self-efficacy (the conviction that one can successfully execute the behavior required to produce the outcome) in multiple behavior change areas, such as parenting or having a structured home environment, to be effective.

Poor satiety and preoccupation with food were recurring themes that ranked highly across several questions. Increased appetite has been reported among nonsyndromic young children with severe obesity, sometimes occurring as early as six months of age.^25,26 Why this behavior happens with these children is not well understood as often they do not exhibit any of the genetic abnormalities seen in children who present with hyperphagia and severe obesity in early childhood.^26,27 However, both Src-homology 2B adaptor protein 1 gene (SH2B1) and melanocortin 4 receptor (MC4R) deficiencies can present with early hyperphagia and severe obesity in early childhood and may have associated behavioral difficulties without other syndromic signs.²⁸

Many providers mentioned observing dysfunctional behaviors around food such as food-related tantrums, eating for nonhunger reasons, lack of satiety, and food seeking. Eating in the absence of hunger is a risk factor for subsequent overweight in childhood that may be tied to the child's temperament, ability to exert control around food, or parental feeding styles.²⁹ Rollins et al., although in slightly older 5–7-year-old girls, found that children with low inhibitory control assessed using the Child Behavior Questionnaire³⁰ were more likely to eat in the absence of hunger and had a greater risk of being overweight especially when mothers provided unlimited access to snacks.

Providers reported unstructured home environments and minimal limit setting for screen time, bedtime, and consumption of sugar-sweetened beverages. Anderson and Whitaker found an increased risk of obesity among children who participated in five or fewer family meals, slept on average less than 10.5 hours a day, or were exposed to two or more hours of screen time.³¹ More importantly, the risk became significantly higher in the presence of all three risk factors.³¹ In the context of a home environment that has less structure and routine, parents may experience difficulty with setting limits if they have inadequate skills to address these food-related challenges or the child has behavioral problems, two themes that resonated in the observations from providers.

The study results likely reflect issues that providers grapple with most often when they care for children with severe early onset obesity. It is interesting that there was variation among providers in the observations of child behavior and in factors that cause obesity. This may inform team-based educational needs. While not implicitly stated by providers, a review of responses and themes suggests that it might have been hard for providers to find positives and strengths of these young children and families. Given that relationally based treatments are commonly used for obesity, how providers perceive their young patients and their families is important. Having a predominantly negative perspective may make it harder for providers to work effectively with these families.

These results suggest an opportunity to further develop and refine training of obesity providers. For example, providers may benefit from enhanced training and assistance with strength-based counseling approaches to increase effectiveness and treatment engagement with families. Furthermore, providers may desire additional training in behavioral techniques to assist families with decreasing food-seeking behavior and developing realistic family routines to meet recommendations for screen time, family meal times, and sleep.

The results of the instrument need to be cautiously interpreted and care taken not to generalize these findings as a definitive description of this population. Physicians often do not accurately recognize or identify emotional, behavioral, or unhealthy weight concerns in their patients.^32–34 Lavigne et al. found that the sensitivity of pediatricians recognizing emotional or behavioral problems based on their observations among preschoolers with proven mental health conditions was only 20.5%.³³ Thus, the observations reported by providers in the study could be an underestimation of the frequency or intensity of the challenges these children and families encounter.

In addition, the themes that emerged are perspectives of providers, not of the families or children themselves. Thus, the results should not be viewed as definitive statements about the young child with severe obesity.

Although questions were nonsuggestive and open ended, participants may still be influenced by bias and stereotypes regarding obesity, race, or gender that are inherent in the society.^35–37 Sabin et al. examined implicit attitudes about weight and race in American Indian Health Service primary care providers and found strong implicit bias toward thinner visual depictions of individuals.³⁸ However, this bias did not seem to influence the provider's weight management treatment approaches for children. Most importantly, our findings offer a lens for potential areas for further research as well as identification of how to improve the training of obesity providers.

Theoretical saturation of qualitative data was achieved with the 72 respondents, suggesting that no more themes would be identified even if there were additional participants. However, as most providers see small numbers of these young children with severe obesity, their observations are likely based on a smaller rather than larger sample, and given the highly specialized group of providers who were surveyed, external generalizability of the results may be limited. Similarly, the survey asked participants to comment on children 5 years and younger with severe obesity. It is possible that responses from participants were mostly related to 2–5-year-olds with severe obesity as severe obesity is not clearly defined in children younger than 2 years.

The addition of a group of respondents not involved in the Expert Exchange as part of the study was carried out to decrease the potential of friend bias, a form of selection bias, as participants in the Expert Exchange may have shared their perceptions with each other on prior occasions, thus influencing each other on the topic. As suggested earlier, conducting a similar semistructured qualitative tool among care providers in other settings and among families will be useful in providing a more comprehensive description of this population of children and comparing areas of agreement and dissonance with our findings.

The value of this study is threefold: it provides a broad description of the observations of an interdisciplinary team of providers regarding the presentations of young children with severe early onset obesity in tertiary care obesity clinics. It offers insight into what providers grapple with when they see these children and highlights challenging areas for the children and their families. The themes may also represent areas the provider is most ill-equipped to address.

Further research is needed to validate these observations and better understand why providers are likely to report specific characteristics and how this may inform provider training. Similarly, it would be interesting to find out how parents perceive these observations, whether there is agreement or dissonance between parents and providers, and how these characteristics may cluster together to offer the potential for targeted interventions. Finally, the results can help generate hypotheses for future qualitative and quantitative studies that investigate components of a behavioral lifestyle intervention that can be most effective at modifying or strengthening parenting skills, addressing appetite dysregulation and unstructured home environments.

Footnotes

Author Disclosure Statement

The authors acknowledge the Children's Hospital Association and the American Academy of Pediatrics as the primary project sponsors for the Expert Exchange. No other competing financial interests exist for any of the authors.

References

Kelly

, Barlow

, Rao

, et al. Severe obesity in children and adolescents: Identification, associated health risks, and treatment approaches: A scientific statement from the American Heart Association. Circulation, 2013; 128:1689–1712.

Gittner

, Ludington-Hoe

, Haller

. Infant obesity and severe obesity growth patterns in the first two years of life. Matern Child Health J, 2014; 18:613–624.

Welch

, Ariza

, Wieczorek

, Binns

. Characteristics of obese children aged 1–4 years at a referral clinic. J Natl Med Assoc, 2008; 100:884–891.

Hales

, Fryar

, Carroll

, et al. Trends in obesity and severe obesity prevalence in us youth and adults by sex and age, 2007–2008 to 2015–2016. JAMA, 2018; 319:1723–1725.

Skinner

, Ravanbakht

, Skelton

, et al. Prevalence of Obesity and Severe Obesity in US Children, 1999–2016. Pediatrics, 2018; 141:e20173459.

Whitaker

, Wright

, Pepe

, et al. Predicting obesity in young adulthood from childhood and parental obesity. N Engl J Med, 1997; 337:869–873.

Ward

, Long

, Resch

, et al. Simulation of Growth Trajectories of Childhood Obesity into Adulthood. N Engl J Med, 2017; 377:2145–2153.

Kumar

, Kelly

. Review of Childhood Obesity: From Epidemiology, Etiology,and Comorbidities to Clinical Assessment and Treatment. Mayo Clin Proc, 2017; 92:251–265.

Steele

. Why isn't bariatric surgery for adolescents catching on?. JAMA Surg, 2013; 148:314–315.

10.

Shomaker

, Tanofsky-Kraff

, Mooreville

, et al. Links of adolescent- and parent-reported eating in the absence of hunger with observed eating in the absence of hunger. Obesity, 2013; 21:1243–1250.

11.

Pasold

, McCracken

, Ward-Begnoche

. Binge eating in obese adolescents: Emotional and behavioral characteristics and impact on health-related quality of life. Clin Child Psychol Psychiatry, 2014; 19:299–312.

12.

Rose

, Nadler

, Mackey

. Impulse Control in Negative Mood States, Emotional Eating, and Food Addiction are Associated with Lower Quality of Life in Adolescents with Severe Obesity. J Pediatr Psychol, 2018; 43:443–451.

13.

Barlow

. Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: A summary report. Pediatrics, 2007; 120(Suppl 4):S164–S192.

14.

Sharifi

, Marshall

, et al. Accelerating progress in reducing childhood obesity disparities: Exploring best practices of positive outliers. J Health Care Poor Underserved, 2013; 24(2 Suppl):193–199.

15.

Sharifi

, Marshall

, Goldman

, et al. Exploring innovative approaches and patient-centered outcomes from positive outliers in childhood obesity. Acad Pediatr, 2014; 14:646–655.

16.

Sharifi

, Marshall

, Goldman

, et al. Engaging children in the development of obesity interventions: Exploring outcomes that matter most among obesity positive outliers. Patient Educ Couns, 2015; 98:1393–1401.

17.

Story

, Neumark-Stzainer

, Sherwood

, et al. Management of child and adolescent obesity: Attitudes, barriers, skills, and training needs among health care professionals. Pediatrics, 2002; 110(1 Pt 2):210–214.

18.

Radovic

, Reynolds

, McCauley

, et al. Parents' role in adolescent depression care: Primary care provider perspectives. J Pediatr, 2015; 167:911–918.

19.

Malas

, Donohue

, Cook

, et al. Pediatric somatic symptom and related disorders: Primary care provider perspectives. Clin Pediatr, 2018; 57:377–388.

20.

Tester

, Phan

T-LT

, Tucker

, et al. Characteristics of Children 2 to 5 Years of Age With Severe Obesity. Pediatrics, 2018; 141:e20173228.

21.

2013 Survey Findings of Children's Hospitals Obesity Services. Available at www.childrenshospitals.org/obesitysurvey Last Accessed May 26, 2015.

22.

Glaser

. Basics of Grounded Theory Analysis: Emergence vs. Forcing. Sociology Press: Mill Valley, CA, 1992.

23.

Patton

. Qualitative Research and Evaluation Methods, 3^rd Edition. SAGE Publications, Inc.: Thousand Oaks, 2002.

24.

Miles

, Huberman

. Qualitative Data Analysis: An Expanded Sourcebook, 2nd Edition. SAGE Publications, Inc.: Thousand Oaks, 1994.

25.

Miller

, Goldstone

, Couch

, et al. Pituitary abnormalities in Prader-Willi syndrome and early onset morbid obesity. Am J Med Genet A, 2008; 146A:570–577.

26.

Farooqi

. EJE Prize 2012: Obesity: From genes to behaviour. Eur J Endocrinol Eur Fed Endocr Soc, 2014; 171:R191–R195.

27.

Cassidy

, Schwartz

, Miller

, Driscoll

. Prader-Willi syndrome. Genet Med, 2012; 14:10–26.

28.

Farooqi

, O'Rahilly

. Genetic Obesity Syndromes. In: Grant SFA (ed), The Genetics of Obesity. Springer Science+Business Media: New York, 2014.

29.

Rothbart

, Ahadi

, Hershey

, Fisher

. Investigations of temperament at three to seven years: The Children's Behavior Questionnaire. Child Dev, 2001; 72:1394–1408.

30.

Rollins

, Loken

, Savage

, Birch

. Maternal controlling feeding practices and girls' inhibitory control interact to predict changes in BMI and eating in the absence of hunger from 5 to 7 y. Am J Clin Nutr, 2014; 99:249–257.

31.

Anderson

, Whitaker

. Household routines and obesity in US preschool-aged children. Pediatrics, 2010; 125:420–428.

32.

Crone

, Zeijl

, Reijneveld

. When do parents and child health professionals agree on child's psychosocial problems? Cross-sectional study on parent–child health professional dyads. [journal article]. BMC Psychiatry, 2016; 16:151.

33.

Lavigne

, Binns

, Christoffel

, et al. Behavioral and Emotional Problems Among Preschool Children in Pediatric Primary Care: Prevalence and Pediatricians' Recognition. Pediatrics, 1993; 91:649–655.

34.

Sayal

, Taylor

. Detection of child mental health disorders by general practitioners. Br J Gener Pract, 2004; 54:348–352.

35.

Teachman

, Brownell

. Implicit anti-fat bias among health professionals: Is anyone immune?. Int J Obes Relat Metab Disord, 2001; 25:1525–1531.

36.

Phelan

, Dovidio

, Puhl

, et al. Implicit and explicit weight bias in a national sample of 4,732 medical students: The medical student CHANGES study. Obesity, 2014; 22:1201–1208.

37.

Puhl

, Wharton

, Heuer

. Weight bias among dietetics students: Implications for treatment practices. J Am Diet Assoc, 2009; 109:438–444.

38.

Sabin

, Moore

, Noonan

, et al. Clinicians' implicit and explicit attitudes about weight and race and treatment approaches to overweight for American Indian children. Childhood Obes, 2015; 11:456–465.