Journal of Pediatric Surgery (2013) 48, 1012–1019 www.elsevier.com/locate/jpedsurg Understanding academic clinicians’ varying attitudes toward the treatment of childhood obesity in Canada: A descriptive qualitative approach Karen Bailey a,b,c,⁎, Julia Pemberton a , Claudia Frankfurter a a Department of Surgery, McMaster Pediatric Surgery Research Collaborative, McMaster University, Hamilton, Ontario, Canada L8N 3Z5 b McMaster Children's Hospital, Hamilton, Ontario, Canada L8N 3Z5 c Hamilton Health Sciences, Hamilton, Ontario, Canada L8N 3Z5 Received 25 January 2013; accepted 3 February 2013 Key words: Pediatric; Obesity; Attitudes; Treatment; Canada Abstract Background: This qualitative study aims to understand academic physicians' attitudes towards the treatment of pediatric obesity in Canada. Methods: A stratified sample of 24 participants (surgeons, pediatricians, family practitioners) were recruited from 4 Canadian regions. Semi-structured interviews were conducted and transcribed. A codebook was developed through iterative data reduction and conceptual saturation ensured. Validity was ensured through triangulation, audit trail, and member-checking. Results: This study revealed 45 themes with regional, specialty, and experiential differences. Quebec and Ontario emphasized education of physicians and parents to improve treatment and favored surgical intervention. Half of surgeons felt surgery was the only successful treatment option, while non-surgeons favored behavioral interventions. Experienced physicians in Western Canada desired more evidence to improve patient care, while inexperienced physicians focused on early detection and home environments. Across Canada participants advocated for program development and system change. Respondents expressed family involvement as integral to treatment success and shifting away from blame and moving towards a healthy lifestyles approach. Conclusions: Canadian regional differences in physicians' attitudes towards pediatric obesity treatment exist, influenced by experience and specialty. We will understand how themes identified in this study influence real life clinical decision making by applying these results to create a discrete choice-based conjoint survey. © 2013 Elsevier Inc. All rights reserved. The rapid rise in obesity among children and adults has reached epidemic proportions in Canada. According to the 2006 Canadian clinical practice guidelines, obesity has ⁎ Corresponding author. Department of Surgery, Hamilton, ON, Canada L8N 3Z5. Tel.: + 1 905 521 2100x73550; fax: +1 905 521 9992. E-mail address: kbailey@mcmaster.ca (K. Bailey). 0022-3468/$ – see front matter © 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jpedsurg.2013.02.019 become “the most prevalent nutritional problem in the world, eclipsing undernutrition and infectious disease as the most significant contributor to ill health and mortality.” It is identified as the key risk factor for many chronic and noncommunicable diseases [1]. The Canadian Community Health Survey estimates 1 in 4 (26%) children and adolescents between the ages of 2 and 17 are overweight, with the national Attitudes toward treatment of childhood obesity in Canada obesity rate rising from 2% to 10% in boys and 2% to 9% in girls. In Canada, 55% of First Nations children living on reserves and 41% living off of reserves are overweight or obese [1,2]. Pediatric health care professionals are struggling to meet the clinical and educational demands required to care for obese patients and their families [3]. Improved understanding of physicians' views and challenges in current practice will enable the development of effective intervention and educational programs. In order to facilitate change, current attitudes and behaviors need to be described and understood. Our aim was to use qualitative interviews to explore physicians' current attitudes, knowledge acquisition, and perceived barriers in care with regard to treating childhood obesity. The results of this study are being used to create a rigorous discrete choice-based conjoint (CBC) survey for the “ACT NOW” quantitative study. 1013 This study was conducted from May to August 2011 at the McMaster Children's Hospital and was approved by the Hamilton Health Sciences Research Ethics Board (REB Approval #: 11-167). single research assistant conducted all telephone interviews using Bell teleconferencing services. Participants received a gift card as a token of appreciation. Qualitative analysis using NVivo® software (version 8.0, QSR International, Melbourne) was conducted by two independent reviewers following the completion of the interviews including a qualitative methodologist (JP). A descriptive thematic analysis approach was used [6,7]. Through an iterative process, the interviews were read and re-read until a whole sense of the interview was reached. Codes were then developed, sorted into emergent categories, and grouped to form themes. Once data saturation was attained, three independent reviewers achieved data reduction through a series of consensus meetings. Disagreements were resolved through discussion and review of the interview transcripts at these meetings. Finally, member checking was conducted through an online survey, using Lime Survey® software. Each interviewee was asked to indicate their level of agreement with each theme using a 7-point Likert scale. Interviewees could provide other comments regarding the results through an open text field section on the survey. Once the thematic analysis was finalized, the data were stratified based on three a priori comparisons: by region, discipline, and level of experience in treating childhood obesity. 1.1. Study sample 1.3. Rigor The study sample consisted of 24 health care providers affiliated with academic institutions across Canada. Stratified purposeful sampling and snowball sampling were used. Key stakeholders were contacted and used to identify additional individuals, to ensure maximum variation and to locate key information-rich participants [4]. Equal representation from across the country was obtained through stratification across each region of Canada (Eastern Canada, Quebec, Ontario, and Western Canada), and within the following disciplines: family medicine, pediatrics, and pediatric surgery. Within each discipline we recruited one non-experienced and one experienced clinician. Experienced clinicians were defined as those with additional training or research experience specifically in pediatric obesity. In consultation with a leading pediatric obesity researcher and Canadian Obesity Network executive members, a list of experienced clinicians was developed. Non-experienced clinicians were selected from each region based on interest in the study. This study was conducted according to the four standard principal criteria guiding qualitative research: credibility, dependability, transferability, and conformability [8]. To ensure credibility, member-checking, a consistent interview guide, and quotes to support results were utilized. Through the establishment of an acceptable intercoder agreement during the coding process, dependability was attained. Conformability was integrated into the study design by reviewing coding as a team and holding consensus meetings. Lastly, by providing a detailed description of the sampling strategy and research methods, the transferability of the elements of this study is upheld. 1. Methods 1.2. Data collection and analysis After exploring the multiple facets of pediatric obesity [5], an interview guide consisting of seven semi-structured questions were developed, piloted, and refined. Once the interview guide was finalized, we contacted potential participants through email and a follow-up telephone call. All participants provided written or verbal consent, and a 2. Results A total of 24 interviews were completed with 12 male and 12 female participants. The participants included 9 (37.5%) pediatric endocrinologists, 8 (33.3%) pediatric surgeons, 4 (16.7%) family physicians, and 3 (12.5%) pediatricians. Interviews were recorded and transcribed verbatim, and lasted a mean time of 16.3 min (SD ± 9.1). The participants' viewpoints were explored in detail, clarifying any ambiguous answers and prompting elaboration on simple replies. The use of a pre-piloted interview guide allowed for targeted discussion and a reduction in overall interview times. Fortyfive emerging themes were identified under nine categories; 1014 K. Bailey et al. the results from this comparative analysis are reported below (Fig. 1). Results were validated by member-checking with a 50% response rate and agreement rate of 84.4% [9]. 2.1. Geographic regions (Table 1) Looking across regions, providers in Quebec identified the presence of stigma or prejudices in the healthcare system or within families concerning obesity the most. The majority of healthcare providers in Eastern Canada felt that obesity status in the healthcare system was not favorable, and is highly regarded as a diagnosis but not a disease. Physicians in Ontario and Quebec noted that lifestyle, history and mental health were highly prevalent components in their decision making algorithm, as compared to those in Western and Eastern Canada. Under the improving care category, healthcare providers in Western Canada almost unanimously emphasized a need for more evidence to guide current practice and understand the long term implications of childhood obesity. Physicians in Quebec and Ontario placed great emphasis on the education of primary and tertiary care physicians, as well as parents. Across all regions, one or two physicians emphasized a need for an attitudinal shift amongst healthcare providers, shifting away from assigning blame and moving towards encouraging healthy lifestyles. Almost all physicians, regardless of region, Fig. 1 Act Now study overview. indicated a need for program development and system change to improve treatment. Opinions on treatment success varied slightly amongst respondents by region. Responses from Ontario placed great emphasis on shifting health behaviors, and the theme of surgery as a means of achieving success appeared in Quebec and Ontario. Across all regions, however, family engagement was cited as key to achieving results. For knowledge acquisition, all regions across Canada made note of their engagement in independent-style knowledge acquisition, which entails self-initiating tasks such as literature readings and peer consultation. A groupbased approach towards learning was also highlighted by health care providers in Ontario, Quebec, and Eastern Canada. The incorporating evidence category revealed that when the results are stratified by region, healthcare providers from Eastern Canada remarked their use of informal consultations with their peers. Responses from Western Canada and Ontario placed greater emphasis on the formal and organized peer reviewed process as a central avenue for evidence integration. 2.2. Health professional discipline (Table 2) When asked about reasons for referral to an obesity treatment program, the respondents clearly separated medical from surgical programs. Reasons for referral to a medical program included availability of a program, clinical characteristics, and cost to the patient. Surgical referral focused around the status of the patient in an established medical program, maturity, and compliance. The treatment approach was similarly split into either medical or surgical-based modalities. There was a wider divide in attitudes and opinions between these two options, with medical treatment (diet, lifestyle and behavioral interventions) being the more widely accepted program. With regard to surgical treatment, the respondents expressed skepticism and a need for evidence of efficacy, long-term follow-up, and transition to adult care plans to be in place before a change in attitude would be possible. A major overall message from all respondents, regardless of location, experience, or role was that any treatment must be multidisciplinary, adopt a patient or family-centered approach, and be coupled with close follow-up. Almost half of the surgeons interviewed felt that surgery is the only effective treatment for obese children, while pediatric endocrinologists, family physicians, and pediatricians felt that focusing on healthy behaviors was a key element in achieving success. Additionally, pediatric endocrinologists emphasized the importance of continuity of care in treating obesity successfully. However, all disciplines felt family involvement was an integral part of attaining weight loss results. Finally, for the knowledge acquisition category, pediatric endocrinologists and surgeons cited both their participation in interactive educational activities in addition to their Attitudes toward treatment of childhood obesity in Canada 1015 Table 1 Comparison by geographic region. Theme Definition Quote Stigma/prejudice A cultural mentality that obese patients are at fault exists, leading to bias and discrimination in society and the healthcare system. Status in healthcare system Clinical exam and history Obesity is referred to as a diagnosis, and not a disease. Lifestyle Contributing factors such as activity, nutrition, screen time, and interaction with peers are considered. An age appropriate mental health assessment is conducted. “So, if you know a baby was born under the strong family history of breast cancer, well I can tell you, they will be surveying that kid from day one, or the parents will be concerned about it. But, identifying that and really treating—letting the parents know that obesity is a disease. Your child is at risk because you and your husband are obese. But, we can intervene as follows so that your child does not have—and so, to recognize it's a disease and let people know it's a disease, it's not a stigma.” “Well, you know what, to be honest with you I think obesity has really—it's just really now becoming recognized as a chronic disease that's important.” “Well, my patients, what I would do first is take a history of the patient and the family, finding out some questions around the sort of history of the weight gain.” “I use the BMI on CDC curves.” “What I usually do is I do a nutritional assessment and an activity assessment.” Mental health Thorough medical, family, sleep and weight histories are taken, and a physical exam is conducted. Practice guidelines Evidence based guidelines developed to inform clinical care. Surgical risks Education on the complications and benefits associated with bariatric surgery. Program development/ education Teach patients and parents about healthy lifestyle choices. Instruct physician and residents about available resources and effective communication. Attitude shift for healthcare providers A change in the health system to remove barriers: the need for a co-morbidity to receive treatment, lack of time in primary health care, lack of space, and overuse of specialists. The government must make changes in funding priorities, increase school involvement to aid in shifting the societal mindset about obesity. “I'd want to get a sense of mental health history, is there any symptoms of anxiety or depression, learning disabilities, any signs of disordered eating or binge eating.” “So I am aware of the Canadian clinical practice guidelines for the treatment and management of adult and pediatric obesity, so it's a great resource.” “Because they've got to understand that they may not enjoy what they're faced with after they have the operation. They won't be able to eat. They may throw up. They may have malabsorptions, maldigestions, all those sorts of symptoms.” “My decision making process involves educating them about the surgical procedures and making sure that they know all of the risks and potential benefits of the surgery, and then allowing them some time to make a decision whether they want to go ahead with it.” “I think sort of, publicity at the primary health care provider level is also key ensuring that, because those are the first point of contact for patients and families and I think if those individuals aren't motivated to help families and patients treat obesity then no matter how many good clinics there are, they just won't be used. So I think education, not only to families and patients but also to physicians that these resources hopefully will become available will be key in sort of making a change.” “I think education is going to be the primary thing. I mean I'm not an expert on how you institute changes in lifestyle in the population at large…but I think that educational resources would be the most important.” “Well, I mean if we put in this category to try to—for example, if you take the cancer patients, well there is a tremendous improvement over the last 40 years in the care of the cancer kid, but nobody does its own thing. Everybody does it according to national or international protocols and everything is centralized. That's—so it means that each time there is a—so there's a number and each time there is a sign that there is an improvement, well, there we are. They go for this particular new protocol. We cannot do this at all levels (Continued on next page) 1016 K. Bailey et al. Table 1 (continued) Theme Definition Group based Activities involving peer interaction, such as rounds, conferences, lectures, and peer meetings. Independent Individual tasks requiring initiative, such as reading literature, obtaining family feedback, self evaluation of practice, peer consultation and checking email alerts. Consult with colleagues without a formal program or meeting. Peer (unsystematic) Peer (systematic) Formal organized adoption of evidence, through quality assurance programs, regular program evaluations, and developing practice guidelines within an institution. independent learning endeavors as elements of their acquisition of knowledge. 2.3. Pediatric obesity experience (Table 3) Under the attitude towards pediatric obesity category there was a stronger expression of frustration with the perception and status of obesity in the healthcare system by physicians experienced in treating obesity, when compared to inexperienced physicians. Across all disciplines regardless of experience level, change in society, lack of nutrition, change in activity level and psychosocial risk factors were identified as the main themes causing obesity. Additionally, experienced physicians perceived the cause of obesity as ‘multi-factorial’ and expressed a need for more evidence in order to improve care. Inexperienced physicians placed greater emphasis on the importance of early detection and screening, as well as a need for change in family behaviors and home environments as means of improving the treatment of obesity. A lack of knowledge around the Canadian clinical guidelines for the management of obesity was apparent during the interviews. 3. Discussion The prevalence of obesity across the nation has reached epidemic proportions. Its cause is complex and multifactorial, affected by social, environmental, and genetic factors [1]. Primary healthcare providers play a key role in the promotion of health in patients, and subsequently their attitudes toward the treatment and management of childhood obesity greatly affect patient care and outcomes [10]. This is the first study to explore the attitudes of academic Quote for the moment so because we are all looking at what we are doing and we don't have a very good system for tracking the progress besides BMI.” “We have regular meetings of the program where we evaluate the results, where we go over each of the patients in the program and try and figure out what we could have done better, you know, what we're going to do next.” “I have several journals that I read on a monthly or at least every couple of month's basis. And I also participate in creation of new knowledge by writing articles and peer reviewing stuff.” “I go to local symposia and talk to my colleagues…[attend] monthly seminars and rounds, we're constantly trying to update each other on what's going on in the field.” “We have regular meetings of the [obesity] program where we evaluate the results, where we go over each of the patients in the program and try and figure out what we could have done better, you know, what we're going to do next.” clinicians toward the medical and surgical treatment of childhood obesity across Canada. These results will be foundational to the next stage of our research; creating a CBC survey. The variance in attitudes across the country by region and experience levels was not expected and highlights the need for programs and education to be sensitive to these differences and tailored accordingly. Interestingly, the large incidence and concerns with obesity amongst Canada's aboriginal youth were not mentioned by any participants during this study which indicates a need to increase awareness of this national problem [2]. Results may be biased as participants voluntarily took part and may represent those with a particular interest in obesity regardless of region, speciality and experience levels. Many participants in Eastern Canada and those with experience expressed negative attitudes towards pediatric obesity, highlighting their frustration and despair with current treatment options and societal stereotypes affiliated with the disease. These perspectives correspond with some of the prevailing negative attitudes towards obesity previously expressed within the larger healthcare community [11] and indicate the need for a societal shift towards a more positive and encouraging outlook on the disease and those experiencing it. A previous survey of doctors indicates that specialized training in obesity management increases physicians' competency and comfort level in treating patients with obesity [12]. The views in Ontario and Quebec indicate that increased education of health care providers is needed. Such training and awareness of effective treatment techniques may serve to remove feelings of hopelessness in physicians and provide them with the skills required to confidently tackle obesity in pediatric patients. Our results demonstrate that any curriculum and knowledge translation activities developed Attitudes toward treatment of childhood obesity in Canada Table 2 1017 Comparison by health professional discipline. Theme (Category) Definition Quote “No, not really. Well that's where I think that we are really, really lacking - really, for our practice. I mean, there is a clinic that you can sort of beg to get a patient into to, to kind of help them out with nutrition—to help the family out with nutrition. But the system is so over taxed that it's very, very difficult.” Surgical referral Criteria including physical exam, mental health, “I've never referred someone for surgical treatment. Well, number one, there's no program. Number two, I'm not sure social environment assessment, behavior and I believe that it's appropriate …” compliance, maturity, and attempt/success in a “The earliest that they would be referred for surgery would be medical program three months, but usually they go through a six month evaluation and treatment program.” “I truly believe that that would be a last-ditch effort and I would almost see that as if you failed the exercise and nutrition center, then you'd go to the surgical.” Surgical treatment Attitudes and appropriateness of the role surgery “We want to make sure they're not suicidal. We want to make sure they're not binge eaters. There's a series of plays in treating obese children, expectations psychological criteria that we look at [prior to surgical surrounding it, the evidence supporting it, involvement of adult surgeons, surgical options, treatment].” “Comparing the bypass to the sleeve, the sleeve is a somewhat needed long term follow up and issues easier operation, potentially, and most importantly, we think it of accessibility. has a lower risk of long-term vitamin deficiencies…so our thinking it hat it's going to be a bit safer to do a sleeve. But that's kind of theoretical, it's not evidence based, there isn't enough experience in adolescents with the sleeve yet for us to really know.” “They have a full medical evaluation, which of course includes Medical treatment Treatment of obesity in children involving laboratory values, but also includes a detailed history and consultations with specialists, collaborative physical exam, sometimes x-rays, and they have a full programs, use of pharmaceuticals, behavior psychological evaluation as well.” modifications, use of technology, and family participation within the context of variable timeframes and program designs. Family (Treatment Family engagement and creating a safe “I think addressing it as a family problem as opposed to a child Success) environment, where blame is removed. problem seems to work.” Shifting away from prescriptive diets “So it's not a very prescriptive program or one size fits all, it's, Health behavior you know, trying to find physical activity that they're ready for focus (Treatment to gradual changes in behavior. and want to try, and also small changes in their diet that we think Success) will make a healthier diet.” Surgery (Treatment A means of achieving significant weight “I think that [the] most successful would have to be surgery.” Success) loss results. “Close follow up. Close follow up is an encouragement, close Continuity of care Patients need to be followed consistently, for long periods of time. follow up, so seeing a patient once a year or once every six (Treatment months is not helpful. I think these kids need regular Success) appointments, close follow up. They need somebody to believe in them and they need for the parents to be on board.” “We have regular meetings of the program where we evaluate the Group based Activities involving peer interaction, such as rounds, conferences, lectures, and peer meetings. results, where we go over each of the patients in the program and (Knowledge try and figure out what we could have done better, you know, Acquisition) what we're going to do next.” Medical referral Criteria including physical exam and history, comorbidities, family participation, motivation, financial issues, accessibility to obesity specific programs for physicians must combine independent and group-based learning approaches. There is an apparent but anticipated disparity in the mindset of healthcare providers based on discipline regarding the preferred treatment options for pediatric obesity. Interestingly, half of the surgeons interviewed believed that surgery was the only successful treatment option, whereas not surprisingly, non-surgeons favored behavioral interventions. Growing evidence which includes a systematic review suggests that children and adolescents who undergo bariatric surgery may 1018 Table 3 K. Bailey et al. Comparison by pediatric obesity experience. Theme Definition Quote “The problem is that—and I occasionally succumb to that, you know, that some doctors have a defeatist attitude. Because indeed, I mean, when the child who is massively overweight walks into the office of a pediatric endocrinologist, we are very, very late in the process that is essentially impossible to reverse completely.” Psychosocial risk Socioeconomic status, mental health, parental “The majority of the kids that we're seeing with severe—what factors lifestyle and home environment. we call severe complex obesity have either—we're seeing a lot Activity level Increase in sedentary lifestyles and a decrease in of strong family history of mental health issues. We're seeing physical activity. slightly more likely to have lower socioeconomic means to be active or have more food insecurity. We're seeing more learning disabilities, more sort of, you know, single parent homes or parents sort of financial constraints, so parents working two or three jobs sort of trying to make ends meet.” Nutrition Lack of nutrition from easier access to fattening “So on the nutrition side of things, I mean kids certainly are— foods linked to financial and time barriers. it's cheaper and easier to eat high fat, high sugary content foods compared to healthier, fresh fruits and vegetables. Particularly in winter time in Canada, when it's hard to get fresh produce available.” “Then there's the whole sort of societal issues, everything from, Society Fast paced and sedentary lifestyle, advertisements for unhealthy foods, perceived danger in community you know, how we plan our neighborhoods, so that there are no sidewalks in suburbs, and issues around marketing of unhealthy with lack of access to community programs and options targeted at kids and teenagers, you know, related to the physical activity at school. sort of fast food industry.” Awareness Increased knowledge of obesity implications, “We need to improve access and heighten awareness of the EBM guidelines, and multidisciplinary programs. multidisciplinary clinics like the exercise and nutrition center.” “Increase the effectiveness and the awareness among the primary care providers to recognize obesity when it starts to develop in children and to institute preventative strategies or treatment strategies at an earlier level, before they get to the point where their BMI is 40 or 50.” Screening Early detection of obesity at a community level. “So I think the thing that would help the most is sort of intervening before children even have comorbidities, so whether that's at the school level or sort of at the primary care level; identifying kids before they're obese and trying to get them on the healthy lifestyles before they get to comorbidities.” Family behavior Changes in the home environment to facilitate “And then, we'll talk about family intervention because I think healthy behaviors. what happens, a lot of time, people want to fix the kid but they don't want to change what's going on in the family. And, that's what really needs to happen. It needs to be a whole family approach.” Hopelessness Healthcare providers feel the system is failing them and their patients, they struggle with a lack of evidence to support successful treatment of obese pediatric patients, especially those who are morbidly obese. anticipate considerable and sustained improvements in their obesity status and overall health as opposed to individuals who undergo surgery later on in life and experience less effective results [13,14]. However, a multidisciplinary approach seems to be foundational for the care of bariatric surgery patients [15]. This literature reinforces the opinions expressed by the majority of participants that multidisciplinary care is needed for pediatric obesity treatment nationally. Pediatric healthcare providers in Canada must understand the risks and benefits of bariatric surgery and know when to appropriately utilize surgical options for their patients. Canadian academic physicians who treat obese pediatric patients may be more inclined to pursue only behavioral methodologies, even when surgery may be the more effective treatment option. With the widespread use of behavioral treatments that rely on lifestyle changes, it must be ensured that intervention methods are sensibly selected, with their effectiveness corroborated by evidence. Behavioral lifestyle interventions compared to standard care or self-help can elicit meaningful reductions in weight. Current literature suggests that behavioral modifications are more promising when integrated into holistic intervention plans [16,17]. No conclusion has yet been reached regarding the most successful long-term medical obesity treatment option for children [18]. Physicians in Western Canada appropriately indicated a need for Attitudes toward treatment of childhood obesity in Canada more evidence to facilitate patient care. As academic physicians we must become leaders in establishing this body of evidence for pediatric obesity treatment. Providers in Ontario, Quebec, and Eastern Canada may need to place a greater emphasis on evidence-based methodologies as a benchmark for the obesity care they deliver. In this study inexperienced physicians stressed early detection and the home environment as key target areas for obesity management. This mindset reflects the evolving trend within the scientific community that early detection in children coupled with appropriate measures can prevent the full onset of obesity and affiliated co-morbidities [19]. Greater emphasis on detection and prevention may be required of experienced physicians, who address obesity in pediatric patients only when the condition has reached an extreme level. Physicians with greater clinical experience had increased frustration; likely reflecting the real challenges faced when working with this patient population and their families [10]. There appears to be an underutilization of the existing Canadian clinical guidelines for the management of obesity [1]. Increasing awareness of these guidelines within Canada and incorporating them into clinical practice are important next steps. Upon analysis of all responses, a fundamental formula for success in the management of obesity emerged. It was apparent that when both a patient and their primary caregivers expressed their willingness to manage obesity, a successful treatment program could be put in place. Conversely, if the caregivers were supportive of changes to manage obesity, but the patient was not, healthcare providers would deem any obesity management plan to be a failure from the outset. If the patient was willing to address the disease, but the parents were not, a failed outcome was likewise anticipated. This finding highlights the importance of supportive home environments in the effectiveness of pediatric obesity treatment, further reinforcing the notion that family-centered interventions are needed to be applied when managing childhood obesity management [20]. All physicians voiced the need for program development and system change. There is a clear need expressed for institutional reform, educational tools, and implementation of rigorous clinical practice guidelines in order to facilitate the delivery of improved childhood obesity care. There are signs of a shift in mentality, with many physicians steering away from blame and moving towards the promotion of wholesome lifestyles. As physician advocates look at childhood obesity with a more supportive perspective one holds out hope that society may follow their lead. 4. Conclusion Confirming the attitudes, some expected and some unanticipated, of physicians across the country has been an important first step in understanding what influences obesity 1019 treatment. There appear to be differences based on region, experience levels and by discipline which will need to be further studied. The information gained will be used as the foundation to inform the attributes of a choice based conjoint study which will survey a larger group of academic physicians across Canada to better understand what influences their decisions to treat childhood obesity. By understanding the attitudes of doctors towards the medical and surgical treatment of pediatric obesity in Canada, we can begin to pave the way towards change and improved care of pediatric patients with obesity. References [1] Lau D, Douketis J, Morrison K, et al. 2006 Canadian clinical practice guidelines on the management and prevention of obesity in adults and children. CMAJ 2007;176:S1-S13. [2] Shields M. 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