Summary

Objective:To assess the attitudes and practices regarding the prevention and management of obesity among primary health care professionals.

Design: A cross-sectional questionnaire survey.

Subjects: 39 doctors and 31 nurses working in four primary care clinics within the 2 months period from October to November 2005.

Main outcome measures: A validated self administered anonymous questionnaire was distributed to all doctors and nurses. The measures included basic demographic data, views on weight management, definitions of success, views regarding the use of drugs, approach to and strategies recommended for weight management, and major obstacles in managing overweight and obesity.

Results: 100% of the participants returned the questionnaires in which 65 of them (93%) were complete. Over 70% of respondents were willing to offer advice on weight control and agreed to spend time on prevention of obesity during their consultation practice. Nevertheless, only half perceived professional satisfaction from weight reduction counselling. Most participants (>75%) knew major parameters to define success of weight management. Concerning the use of drugs in obese patients, less than 15% viewed prescribing drugs as "not useful at all". More than 90% acknowledged the importance of comprehensive assessment of overweight and obese patients. However, only 20% thought that it was very important to see patients together with a spouse or significant other during counselling. More than 90% agreed to give specific advice on low fat, low calorie diet and aerobic exercise to reduce body weight. They seldom referred patients to join commercial or community slimming groups in which, 71% and 42% perceived as "not important" respectively. The most common perceived obstacles in managing obesity were the patient"s low motivation to lose weight (34%), inadequate consultation time (26%) and lack of patient's self awareness of obesity (15%).

Conclusion: There are several barriers in managing obesity in primary care. Strategies including professional training in weight reduction counselling and development of evidence based weight loss programme; and utilization of community resources seem warranted based on this study. Further studies are required to address low professional satisfaction and expectations towards successful weight management among primary health care professionals

Keywords: Overweight, obesity, primary health care, attitudes, practices

摘要

目的：評估基層醫療人員對超重及肥胖的預防及治療的態度及實施方法。

設計：橫切面式問卷調查。

對象：2005年10月至11月期間，向四間基層診所的39名醫生及31位護士進行問卷調查。

測量內容：向各位參加者分發已審核的不記名問卷。內容包括基本人口統計資料，體重管理的意見，成功的定義，對於使用藥物的意見，體重管理的策略，如何推薦方案和治療超重及肥胖問題的主要困難。

結果：100%參加者回覆了問卷，93%(65份)完成調查。70%以上回覆者表示願意提供控制體重的建議並同意在日常工作中分配時間做超重的預防。但只有半數的人士成功提供專業減肥意見後獲得滿足感。多數參與者(>75%)認識管理體重的主要標準。在肥胖者使用藥物的問題上，少於15%的人士認為“沒有作用”。雖然90%以上參加者認同對超重及肥胖病人全面評估的重要性，但只有20%人士認為諮詢時同時接見病人親屬十分重要。盡量超過90%參加者同意給予病人特定建議，包括低脂，低熱量食物及帶氧運動以減少體重。甚少轉介病人參加商業或社區減肥組織，71%及42%認為這些組織“並不重要”。最常見的治療障礙包括病人缺乏減肥動力(34%)，診療時間不足(26%)及病人對超重及肥胖的自我認知不夠(15%)。

結論：基層醫療人員治療超重及肥胖病人有不少障礙。基於本文研究所得，解決方案包括舉辦減低體重方法的專業訓練，發展以實證為本的減肥活動以及充分利用社區資源。其他研究方向包括如何提高基層醫療人員對減肥治療的期望及滿足感。

主要詞彙：超重，肥胖，基層醫療人員，態度，實施

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Introduction

Excessive weight (overweight) and obesity are posing a growing threat to public health throughout the world. The World Health Organization estimates that there are over 300 million obese adults worldwide.¹ According to a local survey conducted in 2003 in Hong Kong, 16.4% of population were overweight and 17.4% were obese.² Overweight and obesity in adulthood are associated with large decreases in life expectancy.³

A focus on the prevention and management of obesity has clear implications for health professionals, a fact that is acknowledged by way of calls for better training of general practitioners, dietitians and other health professionals.⁴ Despite these calls, patient survey indicates that less than one-half of obese individuals are advised by their physicians to lose weight.^5,6 Physician surveys also suggest that doctors are reluctant to address weight management issues, especially among those patients who are not extremely overweight.^7,8 Furthermore, health professionals, including general practitioners and nurses, hold negative attitudes towards their overweight and obese patients.^7,9,10 Other obstacles such as low levels of relevant knowledge and skills on weight management were also noticed among general practitioners.^7,11

There is no large scale local study to address attitudes and practices of overweight and obesity among primary health care professionals. In order to better understand potential barriers to treating these problems, we performed a pilot study targeting doctors and nurses in four primary care clinics.

Method

Subjects

This is a cross-sectional survey performed between October 2005 and November 2005. The sampling frame for this study comprised all doctors and registered nurses in our unit which includes four government primary care clinics. The four clinics are Ngau Tau Kok Family Medicine Training Centre, Chai Wan Families Clinic, Hong Kong Families Clinic and Kowloon Families Clinic. They are all Family Medicine Training Centres accredited by the Hong Kong College of Family Physicians. All the doctors are either trained family physicians or under vocational training in Family Medicine. Nurses involved are employed by Department of Health and there is no compulsory post graduate training in primary care for them. All of them are Chinese.

Survey

A self-administered anonymous questionnaire was developed for this study. An investigator was appointed in each clinic. The investigators would deliver an envelope with a cover letter, a consent form and a copy of the questionnaire to each. The participants were advised to complete and return the questionnaire to the investigators within a month. The validated questionnaire was mainly based on a questionnaire that assessed Australian general practitioners" attitude and practices to obesity management.¹² Definition of obesity using body mass index was modified according to the World Health Organization Asia Pacific Perspective for Asians.¹³

The questionnaire assessed six different aspects. The first part involved personal profile of participant including age, gender and BMI (6 questions). The remaining five domains examined views on weight management (12 questions), definitions of success (6 questions), views regarding the use of drugs (2 questions), approaches to weight management (11 questions) and strategies recommended for weight management (13 questions). For each of these statements of the first three domains, participants were asked to indicate their level of agreement on a five point Likert-type scale (strongly disagree, disagree, neutral, agree and strongly agree for the first two domains and not at all useful, of some use, quite useful, useful and very useful for the third domain). A three point Likert scale (not important, quite important, very important) was employed for the last two domains. An open-ended question about the obstacles in treating or managing overweight and obesity appeared at the end of the questionnaire.

Data analysis

The questionnaires were inspected for completeness and coded for data entry. For the open-ended question, one investigator would try to group responses into domains representing common issues. Statistical analysis of numerical data was performed using SPSS software version 12.0.

Results

Profile of participants

Of the 70 participants in this survey, 100% of the questionnaires were returned and 65 of them (93%) were completed.Table 1summarizes the participant characteristics.

Views on weight management (Table 2)

More than 70% of the participants thought that they should encourage adults with healthy range of body weight to maintain their weight. Between 30% and 40% of participants agreed that most overweight and obese adults should be offered treatment to lose weight. Less than one-third felt that treatment should only be offered to overweight patients with other risk factors. Majority (98%) of doctors acknowledged the important medical benefits can result from small weight loss. On the other hand, relatively few nurses (59%) perceived the beneficial effects.

Over half of respondents realized that only few overweight people can reduce their weight and maintain this loss. More than two-thirds agreed that their time should be best spent in prevention of obesity. However, only one-third of doctors regarded weight reduction counselling as a professionally rewarding job. Interestingly, more nurses (58%) seemed to be satisfied doing this than doctors.

Around 60% of primary care providers disagreed that their best role was to refer patients to other professionals. Most of them (> 80%) were also willing to offer advice on weight control on request. Nevertheless, only half of them were confident in offering treatment to overweight and obese patients.

Definitions of success of weight management (Table 3)

Over three-quarters regarded improvements in health and disease indicators, adoption of healthy eating and exercise, sustained small weight loss and achieved healthy range of weight as measures of success in weight management. Around 60% of participants realized the importance of improved patient"s body image and self confidence. However, only 40% agreed that maintenance of present body weight was a parameter of success.

Views regarding the use of drugs (Table 4)

More than one-third of participants thought that drugs were not useful at all in management of overweight patients while the remaining described them as "of some use". Concerning the management of obesity, more participants realized the important role of drug treatment. Less than 15% viewed prescribing drugs as "not useful at all" and over one-third thought that drugs were "of some use". The remaining half of participants regarded drug treatment as "quite useful", "useful" or "very useful".

Approaches to weight management (Table 5)

All participants viewed assessment of patients" weight history, dietary and physical activity habits as "quite important" or "very important". In addition, most participants (> 90%) thought that assessing patients" motivation, home environment for supportive arrangements / partner, patients" expectations of weight management, patients" definitions of successful outcomes and reviewing patients" progress for more than 6 months were "important" or "very important". Relatively few primary care providers thought that it was very important to see patients together with a spouse or significant other (20%). The primary care providers who thought it was important to refer patients to other health care professionals were also not many (16%) and about the same number thought it important to review patients" progress for more than 2 years (17%).

Strategies recommended for weight management (Table 6)

Over 90% of participants considered advice to eat fewer calories, reduce total fat intake and alcohol, increase fruit and vegetables consumption, do more exercise or be more active, incorporate low-intensity activity into present lifestyle, keep an eating awareness diary and achieve dietary goal through strategic shopping and cooking as "quite important" or "very important". Between 70% and 80% of health care workers perceived the importance of giving advice to reduce dairy foods and red meat, and increase bread or cereal consumption. On the contrary, more than 70% and 40% of participants held the views that it was not important to advise patients to join commercial and community slimming group respectively.

Obstacles in managing overweight / obesity

The most common problems or obstacles experienced by primary care providers are listed in Table 7. There were 53 participants (76%) giving comments on this issue. The problems or obstacles can be classified into providers" and patients" factors. Inadequate consultation time, no structured programme in managing overweight and obesity in clinic and lack of referral sources or community resources for weight reduction were the most common problems encountered by health care providers. On the other hand, they regarded patients" poor motivation to lose weight and maintain weight loss, lack of self awareness of overweight and obesity being problems were the commonest obstacles in patients.

Discussion

This study examined attitudes and practices relating to overweight and obese patients among primary care providers. The findings might provide insights to potential barriers of management of overweight and obese individuals.

Most primary care professionals hold positive and clear views on their roles and responsibilities in managing obesity. They were willing to spend time on this issue in their daily practice. Overseas studies also have similar findings.^12,14 However, only half of the participants were confident in offering treatment to patients and achieve professional satisfaction from weight reduction counselling. These problems were also encountered by other professionals including dietitian.^9,15,16 In our study, about 60% of the respondents realized that only a small percentage of overweight people could reduce their weight and maintain the loss. The pessimistic expectation may partly account for low satisfaction among some primary care providers to tackle overweight and obesity.^9,15 In fact, a study from the US¹⁰ revealed that primary care physicians viewed treatment of obesity to be ineffective compared with treatment of other common chronic diseases. They judged that the effectiveness was comparable to treating drug addiction.

It is encouraging that over three-quarters of respondents knew major parameters to define success of weight management. Nevertheless, more than 20% of them disagreed that maintenance of present body weight over time was a measure of success. This may indicate that some of primary care providers have unrealistic expectation towards the treatment goal.

The vast majority of respondents acknowledged the importance of comprehensive assessment of overweight and obese patients. Nevertheless, relatively few considered participation of spouses or significant others in weight reduction counselling as "very important". Involvement of the family is perhaps the most important adjunct to an individual"s attempt to slim.¹⁷ An overseas study showed that when spouses of overweight subjects were involved in therapy, the results were better than when subjects were treated on their own.¹⁸ Primary care providers can deliver family counselling for this issue.

Almost all respondents agreed to give specific advice on low fat, low calorie diet and aerobic exercise to reduce body weight. However, quite a lot of participants did not acknowledge the importance of reducing dairy food, red meat and increasing bread and cereal consumption. This may be due to different dietary style between Chinese and Caucasian. On the other hand, referring patients to commercial and community slimming group were perceived as "not important" among two-thirds and one-thirds of participants respectively. Similar phenomenon was also presented in other countries^15,16,19 despite evidence to suggest that obese patients are most efficiently supervised in groups.²⁰ A possible explanation is that there is no comprehensive networking between primary care providers and community or commercial slimming groups. In addition, the quality of these groups may be variable.

Most participants thought that time constraint was one of the major obstacles in treating overweight and obesity. Primary care providers have limited time to deliver behaviour therapy, to engage family members and arrange long term follow up for motivated patients. Recent evidence suggests that brief infrequent counselling by physicians (one to three times / year) may be less effective than physician counselling plus weekly or bimonthly counselling from another professional (dietitian, nurse counsellor, commercial weight loss programme).^21,22 Therefore, collaboration with other professionals can relieve the time constraints of primary care workers.

Patient"s motivation to reduce weight is an another key component for success in a weight loss programme. A recent systematic review and meta-analysis on motivational interviewing found that there was a significant effect for motivational interviewing to manage obesity or to increase physical activities.²³ It is recommended that practitioners need to assess the patient"s motivation to enter weight loss therapy, assess the readiness of the patient to implement the plan and then take appropriate steps to motivate the patient for treatment.²⁴

Lack of self awareness of overweight and obesity among patients was also regarded as main barrier to lose weight. A large local study² found that over 34% of overweight persons did not agree that they were overweight. Instead they believed that their weights were about right or even suboptimal. Strategies that increase public awareness of ideal body weight are important. Overseas public health interventions to promote regular walking exercise are successful to reduce weight.²⁵

Limitations

The target groups of this study was the four government primary care clinics and all of them are accredited training centres in Family Medicine. The results of the study may not be generalized to other sectors in primary care. In addition, our survey involved participation of both doctors and nurses and did not assess any potential effects of the gender and occupation of the respondents. The findings may be mixed up and cannot be generalized to particular group of health care providers.

Conclusion

This study assesses attitudes and practices on the prevention and management of obesity among primary health care professionals. Several potential barriers are noticed in this survey. Primary care providers, in general, have low expectation and professional satisfaction in treating overweight and obese patients. Further studies are in need to explore the underlying reasons. In addition, health care workers should be more familiar with active participation of family members and utilization of motivational interviewing in weight reduction counselling. More training in this aspect should be highlighted in both undergraduate and postgraduate medical and nursing curriculums. Furthermore, local evidence based weight loss programme in primary care should be developed to standardize management strategies and relieve frustration among health care providers. Multidisciplinary approach in which health care professionals and community providers could collaborate may improve care of patients with overweight and obesity.

Acknowledgements

I would like to give my sincere thank to Professor David Crawford, Convener of Centre for Physical Activity and Nutrition Research of Deakin University for kind approval to use the questionnaire in this study. My special thanks are to Dr. Luke Tsang and Dr. Lam Wing Kwun for their support in preparing this manuscript. I also wish to thank Dr. Ng Kwok Keung, Dr. Ng Mei Yee and Dr. Tam Ka Wae Tammy for their assistance in coordinating this study.

Key messages

1. Obesity is posing a growing threat to public health throughout the world.
2. The management of obese and overweight individuals by health care professionals is suboptimal.
3. Health care professionals in general have low expectations of success and low satisfaction in the management of overweight and obese patients.
4. More professional training in weight reduction counselling, development of evidence based weight loss programme and utilization of community resources may be warranted.

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References