PAPER Managing obesity: a survey of attitudes and practices among Israeli primary care physicians

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1 (2002) 26, ß 2002 Nature Publishing Group All rights reserved /02 $ PAPER Managing obesity: a survey of attitudes and practices among Israeli primary care physicians Y Fogelman 1 *, S Vinker 2, J Lachter 3, A Biderman 4, B Itzhak 1 and E Kitai 2 1 Department of Family Practice, Central Emek Hospital, Afula and Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel; 2 Department of Family Medicine, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; 3 Department of Gastroenterology, Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel; and 4 Department of Family Medicine, Ben-Gurion University of the Negev, and Klalit Health Services, Beer-Sheva, Israel OBJECTIVES: To document and assess Israeli family physicians (FPs) knowledge, attitudes and practices regarding the management of overweight and obesity. METHODS: Anonymous questionnaires were completed by 510 family physicians (82% compliance rate). The questionnaires were distributed in various continuous medical education sites of FPs in Israel. The measures included attitudes to and resources of knowledge on weight management, views regarding the prescription of drugs, approaches to and strategies recommended for weight loss. RESULTS: In all, 73% of FPs viewed weight management as important and reported that they often treated cases of overweight and obesity, including for patients without concomitant risk factors. The medical advice most frequently offered is: increase physical activity, decrease number of total calories (eat less) and consultation with a dietitian (95, 81 and 58% respectively). However, most responders (72%) believed that they had limited efficacy in treating obesity and considered themselves not well prepared by medical school to treat overweight patients. Some 60% reported feeling that they have insufficient knowledge regarding nutritional issues. Regarding pharmacotherapy for treating obesity, only 66% knew the drugs prescription indications. However, the vast majority (87%) knew about the gradual increase of weight after stopping drug treatment. CONCLUSIONS: Knowledge gaps and ambivalent attitudes toward obesity management were found. More education focusing on obesity, from medical school to post-graduate learning, seems warranted based on these findings. (2002) 26, doi: =sj.ijo Keywords: primary care physician; weight management; obesity; pharmacotherapy Introduction The prevalence of people who are overweight and obese is rapidly increasing in the Western world. 1,2 There are many health risks and associated comorbidities including hypertension, diabetes, ischemic heart disease, gallstones, osteoarthritis and malignancy. 3 5 The Israeli health and nutrition national survey detected a disturbingly high prevalence of obesity in the year In the age group of y, 44% of men and 32% of women were overweight (body mass index (BMI) kg=m 2 ) and *Correspondence: Y Fogelman, PO Box 121, Givat Elah 23800, Israel. fogelman@netvision.net.il Received 31 December 2001; revised 8 March 2002; accepted 8 April 2002 an additional 17% of men and 25% of women were obese (BMI > 30 kg=m 2 ). Secondary as well as primary prevention is an essential part of primary care physicians work in accordance with the current recommendations. 8,9 The primary care physician is in a unique position of influence, which may lead to the adoption of healthy lifestyles and prevent obesity. 7 Advice from the family physician (FP) may prompt weight loss attempts 10 and may encourage other health-promoting behaviors. 11 FPs awareness of and diagnosis of the obese and overweight is low and may contribute to its undermanagement. 12 There is also reluctance to treat patients without comorbidities, 13 as there is to treat the overweight, as opposed to the obese. 14 In an era of rapidly growing prevalence of obesity and the newly introduced anti-obesity medications, it is important to explore the current attitudes and practices of primary care physicians, particularly among

2 1394 non-specialists, specialists and residents in family practice. The aim of this study was to assess attitudes and practices regarding obesity management among Israeli primary care physicians. Section 3 Respondents also provided demographic and professional information such as age, gender, years in practice and professional status. Methods We administered an anonymous questionnaire to FPs participating in continuing medical education (CME) programs affiliated with all academic departments of family medicine throughout Israel. Questionnaires were distributed during the CME sessions conducted throughout the academic year of All participating physicians were actively providing direct patient care during the survey period. The survey was distributed in CME classes, with no incentive to the participants, and collected during the same session, so as to maximize respondents compliance. A significant proportion of all Israeli FPs participate in the CME courses. Three main groups of Israeli FPs take part in CME courses. The first group consists of board-certified family physicians (BCFPs). They tend to be younger than the other groups receiving CME. Those in the second group (non-bcfps) are older and more experienced. They are not board-certified in family practice, as they typically began primary care practice before the formal residency program came into existence. The third group consists of residents in family medicine training. They are required to participate in CME as part of their training. This survey focused on physician attitudes and knowledge regarding obesity. The questionnaire was developed and validated in a focus group of family physicians. The study questions are divided into three sections. Section 1 This section consists of questions concerning physicians approach to obese patients and methods used to achieve patients weight reduction. For example, the doctor was requested to answer: do you advise your patients to increase physical activity as part of a weight reduction scheme? Other issues in this section included sources of knowledge and ways to update this knowledge. Answers to the statements on this section were on the scale: usually, sometimes and rarely. Only the answers of usually were considered as yes Statistical analysis The survey responses were entered into the Excel for Windows database and analyzed in SPSS for Windows. We used descriptive statistics to analyze the responses to each item. Further statistical analysis was conducted to determine the existence of associations between respondents demographic and professional characteristics and their knowledge and attitudes. Chi-square testing was used for categorical variables, and analysis of variance was chosen to analyze continuous variables. Results Five hundred and ten questionnaires were returned, for a response rate of 82%. The average age of respondents was y, with a mean of y in practice (Table 1). An almost equal number of male and female physicians participated in the study (51% females). Only a minority (6.9%) worked in solo practices. Attitudes to overweight and obesity management The majority of FPs (73.5%) reported that they believed that it was part of their role to counsel overweight or obese patients on the risks of obesity, even in the absence of other cardiovascular risk factors. Doctors were asked to rank whether they were prepared to counsel on weight reduction more than on smoking cessation and coping with stress and to estimate the success they tended to achieve with each issue. They felt more prepared (65%) to advise on weight management as compared to the other topics, but they did not report having the impression of having made any difference in the success at making longlasting changes in lifestyle in the above issues. Almost twothirds (62%) of the physicians stated they distribute patientinformation leaflets and 57% of physicians reported that they try to recruit patient s family members into the process. Relatively few (25%) advised group support meetings. The differences between the three groups of physicians regarding Section 2 This section contains questions concerning physicians attitudes toward obese patients. Physicians reported their attitude toward statements such as Obese people lack motivation and lack willpower or reasons why obese people want to lose weight. Answers to the statements on this section were agree or disagree. Table 1 Professional status, age and seniority (number of years in practice) of participant physicians All Residents BCFPs a Non-BCFPs b Number of physicians 510 (100%) 158 (31%) 173 (34%) 179 (35%) Age (mean s.d.) Seniority (y) mean s.d P < for difference between sub-groups. a BCFPs, board certified family physicians; b non-bcfps, not board certified family physicians.

3 these issues as well as other modalities used to manage overweight are presented in Table 2. both). Non-BCFP as opposed to residents and BCFP thought that counseling for weight reduction is easy (P < 0.001) Knowledge and stigma about overweight and obesity Doctors estimates about the current prevalence of adults overweight in Israeli adult population ranged from 8 to 80% (median 30%). In the doctors view the main reasons why obese people want to lose weight were to improve their appearance (85%), general health (42%) and physical fitness (11%). The FPs thought that their influence on weight reduction (30% rank it as very important) was inferior to that of others. While the role of family members had most influence (40%), friends (38%) and the media (32%) also ranked as having a more important role than that of the FP. Judgmental statements about the overweight and knowledge about weight reduction counseling and medications are presented in Table 3. Statements about overweight like: Overweight people tend to be more lazy than normal weight people or Overweight people lack willpower and lack motivation in comparison to normal-weight people were significantly less common among BCFP (P < for Discussion This study examined current approaches and practices used among Israeli FPs in managing overweight. As such, this survey provides valuable insights as to different approaches among different types of primary care physicians, as well as their knowledge and practice towards anti-obesity medications. Among general practitioners, there is high awareness of obesity as a medically relevant issue, and willingness to view weight management as part of practice. Similar results were found in other studies. 13,15 Although FPs are potentially wellplaced to play a key role in the prevention and management of obesity, there are several factors that limit medical practitioners capacity to deliver such interventions. An Israeli survey among persons aged who visited their FP in the last 3 months found that only 16% perceived that they were given advice regarding physical activity and weight reduction. 16 This low rate was perceived by the patients and it might reflect their perspective of full counseling about weight loss management. In Evans s survey, 17 80% of Table 2 Weight reduction methods advised by family physicians (as percentages a ) Method advised All n ¼ 510 Residents n ¼ 158 BCFP b n ¼ 173 Non-BCFP c n ¼ 179 P-value d Increase physical activity NS Reduce total daily calories NS Eat less in general Referral to dietitian advice NS Diet counseling by the FP Behavioral treatment NS Group support meetings Weight reduction medication NS a Percentage of physicians giving the advice always=often. b BCFPs, board certified family physicians; c non-bcfps, not board certified family physicians. d P-value difference between sub-groups. Table 3 Statements on weight reduction rate (as percentages) of FPs who responded yes Statement All FPs n ¼ 510 Residents n ¼ 158 BCFP a n ¼ 173 Non-BCFP b n ¼ 179 P-value c Overweight people tend to be more lazy than < normal-weight people Overweight people lack willpower and lack < motivation in comparison to normal-weight people Counseling on weight reduction is easy < Accurate nutritional and caloric labeling of food NS would contribute to weight reduction Weight reducing medication is indicated when NS BMI less than 30, even in the absence of cardiovascular risk factors Medications are effective in retaining weight loss even after discontinuation < a BCFPs, board certified family physicians; b non-bcfps, not board certified family physicians. c P-value difference between sub-groups.

4 1396 individuals attending weight loss groups had previously been advised by their doctor to lose weight, but guidance on how to do this was generally judged to be poor. Only 22% of the subjects received positive advice and only 23% reported that three doctor s advice was indirectly responsible for their weight loss. In our study FPs ranked themselves as being the influential source of least impact on weight loss for obese patients; they reported believing that family members or friends are more influential. Plausible explanations could be the lack of time, lack of knowledge, stigma and the emphasis in the FP s agenda on curative treatment. The principal treatment advice given by primary care providers was to engage in physical activity (95%). This high rate is greater than detected in previous studies 18,19 and might express the increasing awareness of the importance of aerobic exercise in weight loss management. 16 Public health interventions promoting walking are likely to be one of the most successful initiatives in managing obesity. 20 To eat less, to reduce the number of daily calories and to refer to a dietitian or nutritionist were other frequent suggestions given. In Israel the health care system provides global free access to a dietitian=nutritionist. This makes diet counseling feasible and accessible. On the other hand, FPs workload is high and the time allocated for every patient is low, which makes serious in-depth and repetitive dietary counseling not feasible. Kristeller and Hoerr 14 studied variability among physician attitudes and practices regarding obesity management in six specialty groups. FPs reported treating obesity themselves more than many other specialties, reflecting a more active treatment approach. However, they did not deal with the differences in managing obesity beliefs between FPs of different training levels and age groups. Counseling patients about diet habits remains one of the most underused, but important, parts of the health visit. 9 In a German general practice survey, 92% of FPs attributed great importance to nutritional counseling and concluded it must be improved in primary care. 21 However, non-bsfps reported that they counsel their overweight patients on dietary topics significantly more than BSFPs and residents do. Health professionals, including FPs, too often hold negative or stereotypical attitudes toward their obese patients such as: obese patients lack self control, lack motivation, and are lazy. 11,18,22 In this study a significantly higher rate of disparaging attitudes were self-reported among non-bcfps (45%) as compared to BSFPs and residents (about 20%). A study from the US found that healthcare specialists have strong negative associations toward obese people, indicating the pervasiveness of prejudice against the obese. Notwithstanding, their assumption was that the more experience in caring for obese patients the professionals have, the bias against obese people was reduced. 23 Another study found a relatively high rate of clear stigmatization and in some case discrimination by health care professionals. There is documented discrimination against obese individuals, especially in the fields of employment, education and health care. 24 It has been suggested that obese patients are most efficiently supervised in groups. 25 A relatively small number of Israeli FPs (25%) tend to advise their patients about group counseling sessions. This is still more than the 17% that was found among British GPs, who advise patients to attend slimming groups, 18 but much lower in comparison to 84% reported in a survey from the US. 11 The BCFPs significantly more often tend to advise obese patients to participate in such groups than non-bcfps and residents. A plausible explanation is that the knowledge and skills of BCFPs are better than those of non-bcfps. Thirty-five percent of the Israeli primary care physicians recommended behavioral therapy. Long-term behavior modifications in treating obesity yielded favorable results and are among recommended treatments for obesity. 26,27 Negative counseling attitudes among FPs may reflect a lack of familiarity with effective methods. Health professionals who felt that they had no time for health promotion tend to have a more skeptical view of lifestyle counseling than others. 28 In Israel many of the primary care physicians have a substantial workload. Only 4% of doctors recommended using regular antiobesity drug therapy. The reluctance of the Israeli primary care physician to prescribe pharmacological agents to promote weight loss lies perhaps in the question of whether the potential benefits outweigh the risks. The serious side effects associated with fenfluramine and dexfenfluramine may contribute to the current practice. In a study from the US, obesity experts viewed medications as less important in the treatment for obesity than exercise. 29 Another plausible explanation is the doctors low estimate of the current prevalence of adults overweight in Israel. Their median estimate was 30%, while the measured prevalence that was found in the national survey was nearly twice as high. 6 Conclusions Despite the high prevalence of excess weight in the population, there is only limited information regarding FPs attitudes and practices regarding the prevention and management of overweight. This study highlights some of the obstacles preventing primary care providers, senior as well as residents, in achieving optimal obesity management. Education and increasing awareness, increased sensitivity, and more detailed understanding of the current normative practice, are necessary to determine how best to facilitate FPs contribution to addressing the epidemic of obesity. Acknowledgements This work was supported by a grant from the Israel Association of Family Physicians.

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