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Original Contribution  |   August 2019
Influence of Osteopathic Medical Students’ Personal Health on Attitudes Toward Counseling Obese Pediatric Patients
Author Notes
  • From the Program in Translational Biomedical Sciences at Ohio University in Athens (Mr Whipps and Student Doctor Mort); the Departments of Medicine (Student Doctor Mort) and Family Medicine (Drs Beverly and Guseman) at the Ohio University Heritage College of Osteopathic Medicine in Athens; and the Diabetes Institute at Ohio University in Athens (Drs Beverly and Guseman). 
  • Financial Disclosures: None reported. 
  • Support: None reported. 
  •  *Address correspondence to Emily Hill Guseman, PhD, Department of Family Medicine, Ohio University Heritage College of Osteopathic Medicine, 1 Ohio University, Athens, OH 45701-2979. Email: gusemane@ohio.edu
     
Article Information
Medical Education / Pediatrics / Psychiatry
Original Contribution   |   August 2019
Influence of Osteopathic Medical Students’ Personal Health on Attitudes Toward Counseling Obese Pediatric Patients
The Journal of the American Osteopathic Association, August 2019, Vol. 119, 488-498. doi:https://doi.org/10.7556/jaoa.2019.090
The Journal of the American Osteopathic Association, August 2019, Vol. 119, 488-498. doi:https://doi.org/10.7556/jaoa.2019.090
Abstract

Context: Research has shown that physicians with positive health and lifestyle behaviors have more positive attitudes toward effective counseling, but little is known about how personal health behaviors of medical students influence their attitudes regarding pediatric obesity counseling before entering practice.

Objective: To determine whether the personal health status and habits of osteopathic medical students influence their attitudes toward counseling obese pediatric patients regarding lifestyle behaviors.

Methods: A cross-sectional survey was distributed electronically to first- through fourth-year osteopathic medical students. The survey assessed students’ personal lifestyle habits and their top anticipated barriers to providing pediatric weight counseling.

Results: A total of 200 participants completed the survey. National physical activity recommendations were met by 81 participants (40.5%). These 81 participants had significantly more positive attitudes toward pediatric physical activity counseling than participants who did not meet the recommendations (H=−35.06, P=.001) or those who only met resistance training recommendations (H=40.63, P=.021). Participants with obesity had significantly lower pediatric weight management counseling scores than overweight participants (H=40.77, P=.028). Thirty-one participants (15.5%) consumed a healthy amount of both vegetables and fruit. These 31 participants had significantly higher dietary mean item counseling scores than those who did not (H=−30.40, P=.048). Participants identified the barriers “Time” (137 [68.5%]) and “Difficult for patients to change behavior” (99 [49.5%]) most frequently. Clinical participants identified “Poor or lacking reimbursement” (21 [28.0%]) more frequently than preclinical participants (12 [9.6]).

Conclusion: Medical students who exhibited healthier lifestyle habits were more likely to positively view pediatric obesity management counseling.

While lifestyle and behavior modifications can attenuate or manage certain chronic conditions,1 many children and adults in the United States struggle to achieve physical activity (PA) and dietary recommendations. As of 2015, 51.7% of US adults met aerobic PA recommendations, and 21.7% met both aerobic and weight training recommendations.2 According to the United States’ Report Card on Physical Activity for Children and Youth, 21.6% of persons aged 6 to 19 years met daily PA guidelines.3,4 Younger children were more active than teens; less than 10% of all persons aged 12 to 19 years met the recommendations.3 Similar patterns emerged in dietary habits. In 2015, 9% of adults ate the recommended daily amount of vegetables, and 12% of adults ate the recommended amount of fruit.5 Between 2003 and 2010, the amount of whole fruits consumed by persons aged 2 to 18 years increased from 0.55 to 0.62 fruits daily; however, average daily consumption remained below recommended levels.6 
According to the 2012 National Ambulatory Medical Care Survey, primary care visits accounted for 506 million ambulatory physician visits per year.7 Patients who received weight management counseling from a physician were more likely to change behavior, as supported by data showing that patients who discussed weight status with a physician were significantly more likely to lose 5% of their body weight within a year.8 Expert Committee guidelines first released in 20079 and upheld by the US Preventative Services Task Force in 201710 suggested that primary care physicians should provide patients at risk for weight gain with anticipatory guidance regarding healthy PA and dietary behaviors and should involve the entire family in the change process. Evidence suggests that when compared with other physicians, pediatricians are more likely to counsel their patients in lifestyle behaviors and track overall health progress.11,12 Others have documented that most physicians do not provide effective counseling and recommendations to pediatric patients to initiate longstanding positive weight change behaviors to counter childhood obesity.13,14 Efforts to improve pediatric weight status via interventions targeted through pediatric and primary care clinics have also been ineffective.15,16 
The lifestyle behaviors and attitudes of physicians may be mirrored in their practice. Physicians who adopt more positive health habits seem to be more likely to counsel patients in lifestyle behaviors, have positive attitudes toward PA, and be confident in their ability to counsel patients about PA.17,18 Furthermore, physicians who value exercise and have education in physiologic responses to exercise have been reported to be more likely to provide PA counseling to patients.19,20 There is a lack of evidence regarding how lifestyle behaviors of physicians and future physicians affect childhood obesity counseling. 
We previously21 showed that although osteopathic medical students felt confident providing exercise-related counseling to adult patients, they were not knowledgeable of current PA recommendations. With the current study, we aimed to expand our work to evaluate how medical students’ lifestyle habits are associated with their attitudes toward counseling pediatric patients in obesity management. To our knowledge, this is the first study to explore these relationships among medical students. More specifically, the purposes of this study were to determine whether medical students’ personal health behaviors are predictive of their attitudes toward counseling obese pediatric patients and to describe their perceived barriers to counseling. 
Methods
The study protocol, materials, and recruitment methods were approved by the Ohio University Office of Research Compliance (protocol No.17-E-242). 
Participants
An anonymous, electronic survey was distributed to all first- through fourth-year medical students at a single osteopathic medical school with 3 distinct campuses in Ohio: Athens, Cleveland, and Dublin. First- and second-year students were grouped as preclinical, as they had yet to begin clinical rotations, and third- and fourth-year students were grouped as clinical. The survey opened on November 7, 2017, and a reminder email was sent on November 29, 2017. Participants were entered into a drawing for 1 of 8 available $100.00 gift cards in return for completing the study. 
Measures
A modified version of the National Cancer Institute's Physician Survey of Practices on Diet, Physical Activity, and Weight Control: Questionnaire on Child and Adolescent Care (Sections B1, B3, C1-C8, and C10-C12) was distributed to all students. Items required either Likert-scale or open-ended responses. The original survey was designed to assess physicians’ top perceived barriers to providing pediatric weight counseling, their lifestyle habits, and knowledge regarding pediatric obesity screening within their practice. For the current study, the survey was modified for medical students. The participants could choose from the 12 barriers shown in Table 1. 
Table 1.
Demographic Characteristics of Osteopathic Medical Students Surveyed on Attitudes Toward Counseling Obese Pediatric Patients on Physical Activity, Diet, and Weighta
Total (N=200) Preclinical (n=125) Clinical (n=75)
Gender
 Female 113 (56.5) 70 (56.0) 43 (57.3)
 Male 87 (43.5) 55 (44.0) 32 (42.7)
Race/Ethnicity
 White 158 (79.0) 95 (76.0) 68 (84.0)
 Other 14 (7.0) 13 (10.4) 1 (1.3)
 Black 13 (6.5) 8 (6.4) 5 (6.7)
 Asian 13 (6.5) 8 (6.4) 5 (6.7)
 Hispanic/Latino 4 (2.0) 3 (2.4) 1 (1.3)
 Native Hawaiian/Pacific Islander 2 (1.0) 1 (0.8) 1 (1.3)
Anthropometrics
 Height, m 1.72 (0.09) 1.72 (0.09) 1.72 (0.10)
 Weight, kg 73.24 (16.19) 73.53 (16.02) 73.06 (16.35)
 BMI, kg/m2 24.6 (4.6) 24.6 (4.4) 24.6 (4.8)

a Data are given as No. (%) unless otherwise indicated.

Abbreviations: BMI, body mass index

Table 1.
Demographic Characteristics of Osteopathic Medical Students Surveyed on Attitudes Toward Counseling Obese Pediatric Patients on Physical Activity, Diet, and Weighta
Total (N=200) Preclinical (n=125) Clinical (n=75)
Gender
 Female 113 (56.5) 70 (56.0) 43 (57.3)
 Male 87 (43.5) 55 (44.0) 32 (42.7)
Race/Ethnicity
 White 158 (79.0) 95 (76.0) 68 (84.0)
 Other 14 (7.0) 13 (10.4) 1 (1.3)
 Black 13 (6.5) 8 (6.4) 5 (6.7)
 Asian 13 (6.5) 8 (6.4) 5 (6.7)
 Hispanic/Latino 4 (2.0) 3 (2.4) 1 (1.3)
 Native Hawaiian/Pacific Islander 2 (1.0) 1 (0.8) 1 (1.3)
Anthropometrics
 Height, m 1.72 (0.09) 1.72 (0.09) 1.72 (0.10)
 Weight, kg 73.24 (16.19) 73.53 (16.02) 73.06 (16.35)
 BMI, kg/m2 24.6 (4.6) 24.6 (4.4) 24.6 (4.8)

a Data are given as No. (%) unless otherwise indicated.

Abbreviations: BMI, body mass index

×
To determine attitudes toward pediatric obesity counseling and management, participants responded to questions regarding their practice-related counseling beliefs. Participants rated their personal pediatric counseling attitudes on a 5-point Likert scale, with 5 indicating “strongly agree” and 1 indicating “strongly disagree.” Responses to similar questions addressing 3 domains of health counseling (PA, diet, weight management) were summed and averaged to create a mean item counseling score for all domains. Higher mean item scores represent a more positive attitude toward pediatric obesity counseling. 
Levels of PA were evaluated using participants’ self-reported weekly frequency and time spent in moderate and vigorous aerobic PA as well as frequency of resistance training sessions. Time spent in PA was compared with the current US Department of Health and Human Services’ 2008 Physical Activity Guidelines for Americans, which recommend that adults achieve 150 or more minutes of moderate-intensity PA per week, 75 or more minutes of vigorous-intensity activity per week, or an equivalent combination of the 2.4 Adults should also perform resistance training activities involving all major muscle groups on at least 2 days of the week.4 
To assess dietary habits, participants responded to the frequency of vegetable and fruit intake over the past month. Response options were “never,” “1-3 times last month,” “1-2 times per week,” “3-4 times per week,” “5-6 times per week,” “1 time per day,” “2 times per day,” “3 or more times per day,” “4 or more times per day,” and “5 or more times per day” for various food groups, and responses were used to determine weekly vegetable and fruit intake. Participants were classified into 4 groups: consumed the recommended number of both vegetables and fruits, consumed the recommended number of vegetables only, consumed the recommended number of fruits only, and did not consume the recommended number of vegetables or fruit. We approximated the recommended daily vegetable and fruit intake to mirror the American Healthy People 2020 dietary guidelines for adults.5 Participants who ate vegetables 3 or more times per day were coded as meeting vegetable intake recommendations, and participants who ate fruits 2 or more times per day were coded as meeting fruit recommendations. 
The final sections of the survey assessed self-reported year in medical school, height, weight, race/ethnicity, and gender. Height and weight were reported in inches and pounds, respectively, and were converted to meters and kilograms. Height and weight were then used to determine body mass index (BMI) as kilograms per meters squared. Participants’ BMIs were classified into 3 groups based on standard classification protocol: normal weight (<25.0 kg/m2), overweight (≥25.0 kg/m2 and <30.0 kg/m2), and obese (≥30.0 kg/m2). 
Data Collection
All 926 students enrolled at the Ohio University Heritage College of Osteopathic Medicine received an emailed invitation to participate in the study. Students who were interested in participating clicked on a link to the questionnaire via Qualtrics. Upon clicking the link, they were directed to the electronic consent page. Students choosing to participate clicked a radio button labeled “Yes, I consent to participate in this study. I may withdraw my participation at any time.” To decline, participants clicked a radio button indicating “I decline to participate.” The voluntary nature of participation was emphasized to reduce the potential for coercion. Students were informed that their responses would have no impact on their academic status. If they had questions about the study, students were directed to contact the investigators. Participation in the study lasted approximately 15 minutes. 
Data Analysis
Demographic characteristics were assessed using frequency statistics. Frequencies are presented as sample sizes and sample percentages. Researchers (J.W. and E.H.G.) coded PA responses into 4 groups based on US Department of Health and Human Services PA categories: meeting only aerobic, meeting aerobic and resistance training, meeting only resistance training, or not meeting any PA recommendations. Independent-sample t tests were used to determine whether mean item counseling scores differed between preclinical and clinical groups. Kruskal-Wallis H tests were used to evaluate whether differences exist in attitudes toward counseling among groups in different domains of health (PA, diet, and weight management) with post-hoc Dunn tests with Bonferroni corrections to identify group differences. Participants’ perceived barriers to childhood obesity management counselling were assessed using response frequencies and sample percentages and were separated by year in medical school (preclinical vs clinical). Statistical analyses were performed using SPSS version 24.0 (IBM) and significance was accepted at P<.05. Owing to the exploratory nature of the study, a power analysis was not completed. 
Results
The survey was emailed to all 926 students enrolled at the medical school at the time of the study; of these students, 238 consented to participate (response rate, 25.7%). Thirty-eight participants who did not complete the survey were removed from the analysis, leaving a final sample size of 200. The majority of the sample was female (113 [56.5%]), preclinical (125 [62.5%]), and white (158 [79.0%]) (Table 1). 
Physical Activity
Questions that contributed to each mean item score and mean item counseling scores are shown in Table 2. Eighty-one participants (40.5%) met PA recommendations for both aerobic exercise and resistance training, and 80 (40.0%) met neither aerobic nor resistance training recommendations. Eighteen participants (9%) met only aerobic recommendations, and 21 (10.5%) met only resistance training recommendations. Participants who met all PA recommendations had the highest mean (SD) PA counseling score, indicating a higher positive attitude toward counseling (4.59 [0.35]). Meeting no recommendations (4.34 [0.42]) and meeting only resistance training recommendations (4.32 [0.36]) had the lowest mean (SD) PA counseling scores, indicating less positive counseling attitudes (Table 3). A statistically significant difference was found between the mean PA counseling score by different PA groups (H3=19.02, P<.001), such that the group that met both aerobic and resistance training recommendations had significantly more positive PA counseling attitudes than the group that met no recommendations (H=−35.06, P=.001) and the group that met only resistance training recommendations (H=40.63, P=.021). 
Table 2.
Survey Measures of Osteopathic Medical Students' Attitudes Toward Counseling Obese Pediatric Patients on Physical Activity, Diet, and Weighta
Item Mean (SD)
Physical Activity Item Counseling Score 4.46 (0.41)
 Physicians have a responsibility to promote being adequately physically active with their patients. 4.87 (0.36)
 There are effective strategies and/or tools to help patients be adequately physically active. 4.29 (0.75)
 I am confident in my ability to counsel my patients to be adequately physically active. 4.08 (0.87)
 A physician will be able to provide more credible and effective counseling if he/she is adequately physically active. 4.59 (0.69)
Diet Item Counseling Score 4.43 (0.40)
 Physicians have a responsibility to promote eating a healthy diet with their patients. 4.87 (0.36)
 There are effective strategies and/or tools to help patients eat a healthy diet. 4.39 (0.75)
 I am confident in my ability to counsel my patients to eat a healthy diet. 3.90 (0.85)
 A physician will be able to provide more credible and effective counseling if he/she eats a healthy diet. 4.58 (0.72)
Weight Maintenance Item Counseling Score 4.37 (0.45)
 Physicians have a responsibility to promote maintaining a healthy weight or weight loss with their patients. 4.82 (0.43)
 There are effective strategies and/or tools to help patients maintain a healthy weight or lose weight. 4.25 (0.77)
 I am confident in my ability to counsel my patients to maintain a healthy weight or lose weight. 3.82 (0.90)
 A physician will be able to provide more credible and effective counseling if he/she maintains a healthy weight or loses weight. 4.59 (0.70)
Perceived Barriers to Care No.
 If you were providing routing care to pediatric patients today, what would you think would be the top three barrier to evaluating and/or managing your patient's diet/nutrition, physical activity, and weight in your practice?
 Not enough time 68.5
 Not part of my role 1.5
 Not within my scope of practice 1.5
 I am not adequately trained in this area 39.5
 Too difficult to evaluate and manage 12.0
 Inadequate reimbursement 16.5
 Lack of adequate referral services for diet, physical activity, and weight 34.0
 Fear of offending patient 23.5
 Too difficult for patients to change their behavior 49.5
 Lack of effective tools and information to give patients 20.0
 Lack of effective treatment options 8.5
 Other 5.5

a Response choices were 1 (strongly disagree), 2 (somewhat disagree), 3 (neither agree nor disagree), 4 (somewhat agree), and 5 (strongly agree). Note: Participants could pick up to 3 of their top perceived barriers; therefore, the sum of responses exceeds the total sample size.

Table 2.
Survey Measures of Osteopathic Medical Students' Attitudes Toward Counseling Obese Pediatric Patients on Physical Activity, Diet, and Weighta
Item Mean (SD)
Physical Activity Item Counseling Score 4.46 (0.41)
 Physicians have a responsibility to promote being adequately physically active with their patients. 4.87 (0.36)
 There are effective strategies and/or tools to help patients be adequately physically active. 4.29 (0.75)
 I am confident in my ability to counsel my patients to be adequately physically active. 4.08 (0.87)
 A physician will be able to provide more credible and effective counseling if he/she is adequately physically active. 4.59 (0.69)
Diet Item Counseling Score 4.43 (0.40)
 Physicians have a responsibility to promote eating a healthy diet with their patients. 4.87 (0.36)
 There are effective strategies and/or tools to help patients eat a healthy diet. 4.39 (0.75)
 I am confident in my ability to counsel my patients to eat a healthy diet. 3.90 (0.85)
 A physician will be able to provide more credible and effective counseling if he/she eats a healthy diet. 4.58 (0.72)
Weight Maintenance Item Counseling Score 4.37 (0.45)
 Physicians have a responsibility to promote maintaining a healthy weight or weight loss with their patients. 4.82 (0.43)
 There are effective strategies and/or tools to help patients maintain a healthy weight or lose weight. 4.25 (0.77)
 I am confident in my ability to counsel my patients to maintain a healthy weight or lose weight. 3.82 (0.90)
 A physician will be able to provide more credible and effective counseling if he/she maintains a healthy weight or loses weight. 4.59 (0.70)
Perceived Barriers to Care No.
 If you were providing routing care to pediatric patients today, what would you think would be the top three barrier to evaluating and/or managing your patient's diet/nutrition, physical activity, and weight in your practice?
 Not enough time 68.5
 Not part of my role 1.5
 Not within my scope of practice 1.5
 I am not adequately trained in this area 39.5
 Too difficult to evaluate and manage 12.0
 Inadequate reimbursement 16.5
 Lack of adequate referral services for diet, physical activity, and weight 34.0
 Fear of offending patient 23.5
 Too difficult for patients to change their behavior 49.5
 Lack of effective tools and information to give patients 20.0
 Lack of effective treatment options 8.5
 Other 5.5

a Response choices were 1 (strongly disagree), 2 (somewhat disagree), 3 (neither agree nor disagree), 4 (somewhat agree), and 5 (strongly agree). Note: Participants could pick up to 3 of their top perceived barriers; therefore, the sum of responses exceeds the total sample size.

×
Table 3.
Osteopathic Medical Students' Physical Activity, Diet, and Weight and Their Attitudes Toward Counseling Obese Pediatric Patients on These Factors
No. (%) Mean (SD) Item Counseling Score
Physical Activity
 Meets all recommendations 81 (40.5) 4.59 (0.35)
 Meets aerobic only 18 (9.0) 4.50 (0.46)
 Meets resistance training only 21 (10.5) 4.32 (0.36)
 Meets no recommendations 80 (40.0) 4.34 (0.42)
Diet (Vegetable and Fruit Intake)
 Meets both vegetable and fruit Recommendations 31 (15.5) 4.60 (0.28)
 Meets vegetable only 11 (5.5) 4.36 (0.49)
 Meets fruit only 40 (20.0) 4.49 (0.35)
 Meets no recommendations 118 (59.0) 4.37 (0.42)
Weight Maintenance
 Normal BMI 125 (62.5) 4.37 (0.47)
 Overweight BMI 58 (29.0) 4.43 (0.42)
 Obese BMI 17 (8.5) 4.15 (0.34)

Abbreviations: BMI, body mass index.

Table 3.
Osteopathic Medical Students' Physical Activity, Diet, and Weight and Their Attitudes Toward Counseling Obese Pediatric Patients on These Factors
No. (%) Mean (SD) Item Counseling Score
Physical Activity
 Meets all recommendations 81 (40.5) 4.59 (0.35)
 Meets aerobic only 18 (9.0) 4.50 (0.46)
 Meets resistance training only 21 (10.5) 4.32 (0.36)
 Meets no recommendations 80 (40.0) 4.34 (0.42)
Diet (Vegetable and Fruit Intake)
 Meets both vegetable and fruit Recommendations 31 (15.5) 4.60 (0.28)
 Meets vegetable only 11 (5.5) 4.36 (0.49)
 Meets fruit only 40 (20.0) 4.49 (0.35)
 Meets no recommendations 118 (59.0) 4.37 (0.42)
Weight Maintenance
 Normal BMI 125 (62.5) 4.37 (0.47)
 Overweight BMI 58 (29.0) 4.43 (0.42)
 Obese BMI 17 (8.5) 4.15 (0.34)

Abbreviations: BMI, body mass index.

×
Diet
Thirty-one participants (15.5%) consumed the number of recommended servings of both vegetables and fruit. Eleven participants (5.5%) met only the recommendations for vegetable intake, and 40 participants (20%) met only the recommendations for fruit intake. Participants who consumed the recommended number of both vegetables and fruits had the highest mean dietary counseling score (4.60 [0.28]; H3=8.07, P=.045) compared with the other 3 groups: met vegetable only (4.36 [0.49]), met fruit only (4.49 [0.35]), and met no recommendations (4.37 [0.42]) (Table 3). The post-hoc Dunn test with Bonferroni corrections demonstrated that participants who consumed the recommended number of servings of both vegetables and fruits had significantly higher mean dietary counseling scores than participants who did not consume the recommended number of servings of vegetables or fruit (H=−30.40, P=.048). 
Weight Management
The majority of the sample had a healthy BMI (125 [62.5%]), with the rest classified as overweight (58 [29.0%]) or obese (17 [8.5%]) (Table 3). The normal-weight and overweight groups had higher mean (SD) weight management counseling scores (4.37 [0.47] and 4.43 [0.42]) compared with the obese group (4.15 [0.34]). There was a statistically significant difference in the mean weight management counseling score between weight categories (H2=6.84, P=.033), such that obese participants had significantly lower weight management counseling scores than overweight participants (H=40.77, P=.028). 
Barriers
Among all participants, the most frequently anticipated barrier to providing lifestyle counseling for obese pediatric patients was “Time” (137 [68.5%]) and “Difficulty for patients to change behavior” (99 [49.5%]). Participants in both groups also identified “A lack of referral services” (68 [34.0%]) and “Inadequate training” (79 [39.5%]) among the top perceived barriers. Clinical participants identified “Poor or lacking reimbursement” (21 [28.0%]) more frequently than preclinical participants (12 [9.6%]; Figure). 
Figure.
Frequency and percentage of preclinical and clinical osteopathic medical students identifying barriers to counseling obese pediatric patients on physical activity, diet, and weight.
Figure.
Frequency and percentage of preclinical and clinical osteopathic medical students identifying barriers to counseling obese pediatric patients on physical activity, diet, and weight.
Discussion
Our results suggest that medical students’ personal lifestyle behaviors influence their attitudes toward pediatric lifestyle counseling. Specifically, students’ PA, diet, and BMI were associated with counseling attitudes in each respective area. The current study also identified perceived barriers to lifestyle counseling across the 2 phases of medical training (preclinical and clinical). To our knowledge, this study is one of the first to draw connections between medical students’ lifestyle behaviors and their attitudes toward counseling obese pediatric patients. 
 Although fewer than half of the medical students in this sample met PA recommendations for both aerobic exercise and resistance training, this rate of compliance greatly exceeded that reported for adults in the general US population (21.7%).2 The participants who met PA recommendations had more favorable attitudes toward PA counseling. These findings are consistent with previous studies of primary care physicians and medical students.21,23,24 Furthermore, the current study adds to existing literature showing that primary care physicians generally consider PA counseling to be an important part of their scope of practice.25 Osteopathic medicine further emphasizes the role of lifestyle in patient care. In clinical practice, primary care physicians who are physically active are more likely to provide PA counseling to their patients.23 Similar patterns were seen in a study24 that included practicing physicians and medical students, although adherence to resistance training recommendations was not assessed. It was demonstrated that obese physicians and students were less confident about providing PA counseling even if they personally met recommendations for moderate PA.24 This finding, combined with the current study's finding that students with obesity reported lower mean weight management counseling scores than those of other weight classifications, suggests that there may be an interaction between personal weight status and confidence regarding behavior counseling that could be partially independent of personal health behaviors. Because of the increasing pressure on physicians to address pediatric obesity, it is important to understand how the behaviors of medical students may influence how they interact with young patients. 
Participants in this study generally felt confident in their ability to counsel patients about PA. Research has shown that first-year medical students generally express confidence in this domain despite inadequate knowledge of PA recommendations,21 a finding that is consistent with the current study. Physician confidence may decrease as time in practice increases, as shown by Diehl et al25 in a study of more than 4000 primary care physicians. In that study, physicians who had been in practice longer felt less competent at effectively promoting PA among their patients.25 This finding suggests that confidence may be highest early in a physician's career and may decrease with patient contact over time. Additional studies with an appropriate prospective design are necessary to fully answer this question. 
Most medical students in the current sample did not consume the daily recommended number of both vegetables and fruits. This finding is consistent with previous research.26 Additionally, the findings suggest that people who consume the recommended quantity of both vegetables and fruits also have more positive attitudes toward dietary counseling. These findings are supported by a study27 of preventive counseling attitudes in Colombian medical students. The results suggest that improving the diet of medical students may improve their willingness to provide dietary counseling to pediatric patients. 
In general, participants in the current study felt confident that they would be able to counsel pediatric patients about their diet. A previous study28 of medical students from the same university demonstrated that, although they were confident in their ability to provide nutrition counseling, they lacked knowledge of the appropriate dietary recommendations. The low vegetable and fruit intake in the current participants could be explained by their lack of knowledge regarding dietary recommendations. Other studies have examined confidence in counseling through the lens of personal nutrition. Foster et al29 showed that medical students believed they generally had a healthy diet but that there was room for improvement. Yet, medical students also had high confidence in the ability of physicians to alter their patients’ diets.29 This work was limited to opinions regarding adulthood counseling. Similar to the present study, participants tended to eat fewer fruits and vegetables than recommended but were confident in providing dietary counseling. 
Obese participants expressed less positive attitudes toward weight management counseling than normal-weight or overweight participants. One study30 showed that medical students who participated in personal weight management programs improved their BMI while increasing their empathy toward patients who had difficulty managing their weight. Additional research should focus on determining what factors influence medical students’ perception of the importance of pediatric weight counseling in the prevention of obesity so that appropriate educational interventions can be applied. While there has been some work evaluating weight bias among medical students,31 few studies have evaluated how specific personal lifestyle behaviors of medical students relate to how they envision counseling younger populations regarding weight management. 
Similar to other research, the most common perceived barriers to pediatric obesity counseling were insufficient time, a perceived lack of effectiveness, lack of reimbursement, and inadequate training.25,32-34 Changes in reimbursement models for preventive medical services are necessary to increase lifestyle counseling in the future.32 In the meantime, brief training sessions that provide medical students with the education and confidence to engage in lifestyle counseling with younger populations are needed. Counseling youth requires cooperation by both children and their caretakers, as many children do not have control over some of their lifestyle behaviors (eg, access to PA opportunities, household food availability). This training can be included in the preclinical education in integrated learning laboratories, simulations, or early clinical experiences. Recent interventions have demonstrated promise when using tailored approaches, such as the Transtheoretical Model35 and the 5As (ask, advise, assess, assist, arrange).36-39 Incorporating these approaches in preclinical education will help reinforce the need to make lifestyle counseling a systemic, sustained part of medical care.32 These approaches can be delivered in 1 to 3 minutes,39 which may allay students’ perceived concerns for insufficient time. Finally, encouraging physicians-in-training to address both child and parent barriers and arrange follow-up visits or referrals will train students to provide ongoing support and maintenance.39,40 
Limitations and Future Research
This study's limitations include the cross-sectional design, use of self-reported data, and limited data collection within an individual medical school. Having data from a single institution may limit the generalizability of this research to other schools, and the self-report method may be prone to response bias. Students in this program receive limited lecture material regarding diet obesity in children; as such, we were not able to evaluate the effectiveness of course material. Future research should target a larger more diverse sample, including multiple osteopathic and allopathic medical schools and test the effectiveness of educational material developed to improve pediatric weight management counseling. 
Conclusion
The findings suggest that medical students have overall positive attitudes toward PA, diet, and weight management counseling for obese pediatric patients. The most positive counseling attitudes were found among students who led healthier lifestyles themselves, and obese students were generally less confident in their abilities to provide weight management counseling. These findings may suggest that students’ confidence is driven by personal experience with lifestyle behaviors, particularly in the context of previous studies that have shown a mismatch between knowledge of recommendations and confidence in providing counseling. Medical educators should strive to incorporate specific education regarding PA, dietary recommendations, and weight management for children and adults throughout preclinical and clinical experiences to address the ongoing childhood obesity epidemic. 
Author Contributions
Mr Whipps and Dr Guseman provided substantial contributions to conception and design and acquisition of data; all authors provided substantial contribution to analysis and interpretation of data; all authors drafted the article and revised it critically for important intellectual content; all authors gave final approval of the version of the article to be published; and all authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. 
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Figure.
Frequency and percentage of preclinical and clinical osteopathic medical students identifying barriers to counseling obese pediatric patients on physical activity, diet, and weight.
Figure.
Frequency and percentage of preclinical and clinical osteopathic medical students identifying barriers to counseling obese pediatric patients on physical activity, diet, and weight.
Table 1.
Demographic Characteristics of Osteopathic Medical Students Surveyed on Attitudes Toward Counseling Obese Pediatric Patients on Physical Activity, Diet, and Weighta
Total (N=200) Preclinical (n=125) Clinical (n=75)
Gender
 Female 113 (56.5) 70 (56.0) 43 (57.3)
 Male 87 (43.5) 55 (44.0) 32 (42.7)
Race/Ethnicity
 White 158 (79.0) 95 (76.0) 68 (84.0)
 Other 14 (7.0) 13 (10.4) 1 (1.3)
 Black 13 (6.5) 8 (6.4) 5 (6.7)
 Asian 13 (6.5) 8 (6.4) 5 (6.7)
 Hispanic/Latino 4 (2.0) 3 (2.4) 1 (1.3)
 Native Hawaiian/Pacific Islander 2 (1.0) 1 (0.8) 1 (1.3)
Anthropometrics
 Height, m 1.72 (0.09) 1.72 (0.09) 1.72 (0.10)
 Weight, kg 73.24 (16.19) 73.53 (16.02) 73.06 (16.35)
 BMI, kg/m2 24.6 (4.6) 24.6 (4.4) 24.6 (4.8)

a Data are given as No. (%) unless otherwise indicated.

Abbreviations: BMI, body mass index

Table 1.
Demographic Characteristics of Osteopathic Medical Students Surveyed on Attitudes Toward Counseling Obese Pediatric Patients on Physical Activity, Diet, and Weighta
Total (N=200) Preclinical (n=125) Clinical (n=75)
Gender
 Female 113 (56.5) 70 (56.0) 43 (57.3)
 Male 87 (43.5) 55 (44.0) 32 (42.7)
Race/Ethnicity
 White 158 (79.0) 95 (76.0) 68 (84.0)
 Other 14 (7.0) 13 (10.4) 1 (1.3)
 Black 13 (6.5) 8 (6.4) 5 (6.7)
 Asian 13 (6.5) 8 (6.4) 5 (6.7)
 Hispanic/Latino 4 (2.0) 3 (2.4) 1 (1.3)
 Native Hawaiian/Pacific Islander 2 (1.0) 1 (0.8) 1 (1.3)
Anthropometrics
 Height, m 1.72 (0.09) 1.72 (0.09) 1.72 (0.10)
 Weight, kg 73.24 (16.19) 73.53 (16.02) 73.06 (16.35)
 BMI, kg/m2 24.6 (4.6) 24.6 (4.4) 24.6 (4.8)

a Data are given as No. (%) unless otherwise indicated.

Abbreviations: BMI, body mass index

×
Table 2.
Survey Measures of Osteopathic Medical Students' Attitudes Toward Counseling Obese Pediatric Patients on Physical Activity, Diet, and Weighta
Item Mean (SD)
Physical Activity Item Counseling Score 4.46 (0.41)
 Physicians have a responsibility to promote being adequately physically active with their patients. 4.87 (0.36)
 There are effective strategies and/or tools to help patients be adequately physically active. 4.29 (0.75)
 I am confident in my ability to counsel my patients to be adequately physically active. 4.08 (0.87)
 A physician will be able to provide more credible and effective counseling if he/she is adequately physically active. 4.59 (0.69)
Diet Item Counseling Score 4.43 (0.40)
 Physicians have a responsibility to promote eating a healthy diet with their patients. 4.87 (0.36)
 There are effective strategies and/or tools to help patients eat a healthy diet. 4.39 (0.75)
 I am confident in my ability to counsel my patients to eat a healthy diet. 3.90 (0.85)
 A physician will be able to provide more credible and effective counseling if he/she eats a healthy diet. 4.58 (0.72)
Weight Maintenance Item Counseling Score 4.37 (0.45)
 Physicians have a responsibility to promote maintaining a healthy weight or weight loss with their patients. 4.82 (0.43)
 There are effective strategies and/or tools to help patients maintain a healthy weight or lose weight. 4.25 (0.77)
 I am confident in my ability to counsel my patients to maintain a healthy weight or lose weight. 3.82 (0.90)
 A physician will be able to provide more credible and effective counseling if he/she maintains a healthy weight or loses weight. 4.59 (0.70)
Perceived Barriers to Care No.
 If you were providing routing care to pediatric patients today, what would you think would be the top three barrier to evaluating and/or managing your patient's diet/nutrition, physical activity, and weight in your practice?
 Not enough time 68.5
 Not part of my role 1.5
 Not within my scope of practice 1.5
 I am not adequately trained in this area 39.5
 Too difficult to evaluate and manage 12.0
 Inadequate reimbursement 16.5
 Lack of adequate referral services for diet, physical activity, and weight 34.0
 Fear of offending patient 23.5
 Too difficult for patients to change their behavior 49.5
 Lack of effective tools and information to give patients 20.0
 Lack of effective treatment options 8.5
 Other 5.5

a Response choices were 1 (strongly disagree), 2 (somewhat disagree), 3 (neither agree nor disagree), 4 (somewhat agree), and 5 (strongly agree). Note: Participants could pick up to 3 of their top perceived barriers; therefore, the sum of responses exceeds the total sample size.

Table 2.
Survey Measures of Osteopathic Medical Students' Attitudes Toward Counseling Obese Pediatric Patients on Physical Activity, Diet, and Weighta
Item Mean (SD)
Physical Activity Item Counseling Score 4.46 (0.41)
 Physicians have a responsibility to promote being adequately physically active with their patients. 4.87 (0.36)
 There are effective strategies and/or tools to help patients be adequately physically active. 4.29 (0.75)
 I am confident in my ability to counsel my patients to be adequately physically active. 4.08 (0.87)
 A physician will be able to provide more credible and effective counseling if he/she is adequately physically active. 4.59 (0.69)
Diet Item Counseling Score 4.43 (0.40)
 Physicians have a responsibility to promote eating a healthy diet with their patients. 4.87 (0.36)
 There are effective strategies and/or tools to help patients eat a healthy diet. 4.39 (0.75)
 I am confident in my ability to counsel my patients to eat a healthy diet. 3.90 (0.85)
 A physician will be able to provide more credible and effective counseling if he/she eats a healthy diet. 4.58 (0.72)
Weight Maintenance Item Counseling Score 4.37 (0.45)
 Physicians have a responsibility to promote maintaining a healthy weight or weight loss with their patients. 4.82 (0.43)
 There are effective strategies and/or tools to help patients maintain a healthy weight or lose weight. 4.25 (0.77)
 I am confident in my ability to counsel my patients to maintain a healthy weight or lose weight. 3.82 (0.90)
 A physician will be able to provide more credible and effective counseling if he/she maintains a healthy weight or loses weight. 4.59 (0.70)
Perceived Barriers to Care No.
 If you were providing routing care to pediatric patients today, what would you think would be the top three barrier to evaluating and/or managing your patient's diet/nutrition, physical activity, and weight in your practice?
 Not enough time 68.5
 Not part of my role 1.5
 Not within my scope of practice 1.5
 I am not adequately trained in this area 39.5
 Too difficult to evaluate and manage 12.0
 Inadequate reimbursement 16.5
 Lack of adequate referral services for diet, physical activity, and weight 34.0
 Fear of offending patient 23.5
 Too difficult for patients to change their behavior 49.5
 Lack of effective tools and information to give patients 20.0
 Lack of effective treatment options 8.5
 Other 5.5

a Response choices were 1 (strongly disagree), 2 (somewhat disagree), 3 (neither agree nor disagree), 4 (somewhat agree), and 5 (strongly agree). Note: Participants could pick up to 3 of their top perceived barriers; therefore, the sum of responses exceeds the total sample size.

×
Table 3.
Osteopathic Medical Students' Physical Activity, Diet, and Weight and Their Attitudes Toward Counseling Obese Pediatric Patients on These Factors
No. (%) Mean (SD) Item Counseling Score
Physical Activity
 Meets all recommendations 81 (40.5) 4.59 (0.35)
 Meets aerobic only 18 (9.0) 4.50 (0.46)
 Meets resistance training only 21 (10.5) 4.32 (0.36)
 Meets no recommendations 80 (40.0) 4.34 (0.42)
Diet (Vegetable and Fruit Intake)
 Meets both vegetable and fruit Recommendations 31 (15.5) 4.60 (0.28)
 Meets vegetable only 11 (5.5) 4.36 (0.49)
 Meets fruit only 40 (20.0) 4.49 (0.35)
 Meets no recommendations 118 (59.0) 4.37 (0.42)
Weight Maintenance
 Normal BMI 125 (62.5) 4.37 (0.47)
 Overweight BMI 58 (29.0) 4.43 (0.42)
 Obese BMI 17 (8.5) 4.15 (0.34)

Abbreviations: BMI, body mass index.

Table 3.
Osteopathic Medical Students' Physical Activity, Diet, and Weight and Their Attitudes Toward Counseling Obese Pediatric Patients on These Factors
No. (%) Mean (SD) Item Counseling Score
Physical Activity
 Meets all recommendations 81 (40.5) 4.59 (0.35)
 Meets aerobic only 18 (9.0) 4.50 (0.46)
 Meets resistance training only 21 (10.5) 4.32 (0.36)
 Meets no recommendations 80 (40.0) 4.34 (0.42)
Diet (Vegetable and Fruit Intake)
 Meets both vegetable and fruit Recommendations 31 (15.5) 4.60 (0.28)
 Meets vegetable only 11 (5.5) 4.36 (0.49)
 Meets fruit only 40 (20.0) 4.49 (0.35)
 Meets no recommendations 118 (59.0) 4.37 (0.42)
Weight Maintenance
 Normal BMI 125 (62.5) 4.37 (0.47)
 Overweight BMI 58 (29.0) 4.43 (0.42)
 Obese BMI 17 (8.5) 4.15 (0.34)

Abbreviations: BMI, body mass index.

×