Doctors Underestimate Obese People's Desire to Lose Weight

Liam Davenport

May 02, 2019

GLASGOW, Scotland — People with obesity are aware that it is a serious condition and are highly motivated to lose weight, but shy away from asking healthcare professionals for help because they assume it's their own responsibility.

These were the findings of a survey of over 14,500 people with obesity presented here at the European Conference on Obesity (ECO) 2019 and simultaneously published in Diabetes, Obesity and Metabolism.

The Awareness, Care & Treatment in Obesity Management — An International Observation (ACTION IO) study included people from 11 countries in Europe, Central and South America, the Middle East, and Australasia.

In addition, almost 2800 healthcare professionals, half of whom were GPs, were surveyed, revealing that, by and large, they misunderstand what their patients feel and want in relation to obesity. For example, many clinicians thought people with obesity would be offended if they offered advice on weight loss, but in reality, only 3% of people with obesity said this was the case.

And more than 80% of people with obesity said they had made serious attempts to lose weight, but only 54% had discussed their weight with a healthcare professional and they had waited an average of 6 years from when they started struggling with their weight to do so.

However, only 35% of healthcare professionals thought that their patients had tried to lose weight.

Perhaps of greater concern, neither people with obesity nor healthcare professionals showed much confidence in the efficacy of proven obesity treatments, with less than 40% believing in prescription medications and less than 50% thinking it would be helpful to see a dietician.

Also, less than 40% of healthcare professionals thought that bariatric surgery was an effective weight loss management option.

Experts surveyed by Medscape Medical News say there is much to learn from these findings that could help improve the treatment of obesity.

Let's Talk About Obesity

During a press conference, Ian Caterson, MBBS, PhD, of the Boden Institute, Charles Perkins Centre, University of Sydney, NSW, Australia, who led the ACTION IO study steering committee, said, "people with obesity are motivated to lose weight and are trying to do it themselves."

He therefore believes there is an opportunity for physicians to intervene earlier and they need to have an effective conversation "about obesity."

Caterson said there are conflicting data from the survey, in that physicians said they had "minimal fear" of causing offense to patients by talking about their weight, but at the same time said they "don't want to bring it up" for exactly that reason.

He added: "Obesity's here, obesity's a disease. There is a biological basis as well as an individual problem with obesity, and there is clinical management that needs to be discussed and implemented."

Invited to comment, Donna H. Ryan, MD, Pennington Biomedical Research Center, Baton Rouge, Louisiana, said that, in general, the current results are very similar to those of the US version of the ACTION study, published in 2018.

However, she noted that US physicians were more likely than their international counterparts to discuss an obese individual's weight with them, at 74% versus 54%, but less likely to have then diagnosed them with the condition, at 55% versus 67%.

"This is because we have [a] sad history where our insurance companies would not fund weight management services, and in fact, if you put a diagnosis for an office visit as would not be reimbursed."

"So it's very frequent for healthcare providers in the United States to code for hypertension, prediabetes, diabetes, dyslipidemia, knee pain…anything but obesity, because they have been penalized in the past for that obesity diagnosis," she explained.

As to how the current results can be turned into concrete action, she said that, as well as educating patients, "we've got a big job ahead to reach our healthcare providers. To do this, I believe we need to go where the need for education exists, and that's to our primary care [colleagues]."

"They need [to] understand [not] just the biology obviously our patients are struggling with obesity...And they need to know more about evidence-based therapies," as they are "undervaluing" them.

To help with that, Ryan pointed to two publications that will be published in Obesity in June.

One is a standard of care for providers and payers developed by the STOP Obesity Alliance, and the other is a list of obesity competencies for trainees, primary care physicians, and obesity specialists.

"These two things are important," Ryan said, if healthcare providers are to know "where the bar is set."

"So, steal this idea. This is something you need to be doing back home in your countries."

Survey Details: Mostly a Disconnect Between Patients and Physicians

Caterson said that although obesity is recognized as a disease by bodies such as the World Health Organization and American Medical Association, patients are often not diagnosed with the condition and face stigma and discrimination.

Even when it is diagnosed, few patients end up having their obesity managed as a chronic disease, with the US ACTION study estimating that just 24% of people with obesity had weight-related follow-up with a healthcare professional.

To get an international perspective on perceptions of obesity and its management, the researchers developed separate questionnaires for people with obesity and healthcare professionals. These were then translated into the native language of the 11 participating countries and pre-tested to confirm they would be understood. People with obesity and healthcare professionals were then invited to take part in an online panel.

Participants were adults with a body mass index ≥ 30 kg/m2, or ≥ 25 kg/m2 in Japan and South Korea, and had not had significant, unintentional weight loss in the previous 6 months, among other criteria.

Healthcare professionals needed to have been in practice for ≥ 2 years, spent ≥ 70% of their time in direct patient care, and seen ≥ 100 patients in the past month of whom ≥ 10 were obese.

From across the 11 countries, 14,502 people with obesity took part in the survey, at a mean response rate of 20%. They were evenly split between men and women, and the mean age was 43 years. Over 60% of participants had obesity class I and 74% had at least one comorbidity.

The survey was also completed by 2785 healthcare professionals, at a response rate of 17%; 70% were men and their mean age was 48 years.

Of the healthcare professionals, 51% were primary care physicians, 18% were diabetologists or endocrinologists, and 11% were cardiologists.

The results showed that 68% of people with obesity and 88% of healthcare professionals viewed obesity as a disease. Moreover, 82% and 76%, respectively, rated it as having an impact on a person's overall health.

Agreement between people with obesity and healthcare professionals largely ended there, however, as 81% of the former and only 30% of the latter thought that weight loss was the complete responsibility of the patient.

Conversely, 26% of people with obesity but 80% of healthcare professionals felt that the clinician has a responsibility to contribute to the patient's weight loss effort.

Healthcare professionals also underestimated how motivated patients were to lose weight, which they rated at only 31% but people with obesity rated at 48%.

Furthermore, 81% of people with obesity said they had made at least one serious attempt to lose weight, at a mean of four attempts, while healthcare professionals thought that only 30% of patients had tried to lose weight.

People With Obesity Wait 6 Years to Talk to Physician About It

Similarly to the US data, only 54% of people with obesity reported discussing their weight with their healthcare professional in the past 5 years, with only 36% actually being diagnosed with the disease and just 21% receiving weight-related follow-up.

On average, people with obesity said they waited 6 years from when they first started struggling with their weight to first discussing it with a healthcare professional.

Interestingly, 46% of people with obesity thought that they initiated the first conversation about weight, but 66% of healthcare professionals thought they had.

More importantly, 64% of people with obesity said they felt positive about healthcare professionals talking about their weight, with 33% saying it motivated them, 32% saying it gave them hope, and 28% saying it made them feel supported.

Only 3% of people with obesity said that their healthcare professional discussing their weight offended them.

The main reason for not talking about weight for people with obesity was because they felt that weight management was the patients' responsibility alone (44% of respondents), with which only 9% of healthcare professionals agreed.

Healthcare professionals once again misunderstood their patients' views, with 71% saying patients were not interested in losing weight, compared with just 7% of people with obesity.

Moreover, 68% of clinicians thought their patients were not motivated to lose weight, which was the case for only 20% of people with obesity. And 47% of clinicians thought there were more important things to discuss, with which only 16% of people with obesity agreed.

Healthcare professionals also thought that 46% of their patients do not believe they are able to lose weight, but the reality is only 15% of people with obesity felt that way.

Neither Group Rates Obesity Drugs, Dieticians

Curiously, the area where healthcare professionals and people with obesity were in greater agreement was in their perception of the long-term effectiveness of interventions to control weight.

They broadly agreed that diet, healthy eating, and exercise were beneficial, although people with obesity were more convinced of the effectiveness of specific or elimination diets and formal exercise programs/gym membership.

Surprisingly, only 40% of people with obesity and 30% of healthcare professionals thought prescription weight loss medications were effective, and just 38% and 46%, respectively, thought it was a good idea to see a dietician.

And both groups were less convinced of the value of consulting an obesity specialist, at 36% each.

Meanwhile, healthcare professionals were remarkably unpersuaded about the efficacy of surgery, at only 38%, compared with 63% of people with obesity.

More people with obesity believed in the efficacy of over-the-counter weight loss medications than healthcare professionals, at 25% versus 8%.

People with obesity also believed more strongly than healthcare professionals in the efficacy of stress and sleep quality management to help them with their quality of life, although neither group rated such interventions highly.

Great Opportunities to Improve Obesity Management

Summarizing the findings, Jason Halford, PhD, chair in biological psychology and health behavior, University of Liverpool, UK, said: "What is interesting, and we keep coming back to, is that people with obesity and healthcare practitioners stated they recognized obesity as a chronic disease. That's great."

"But the people with obesity then went on to assume complete responsibility for their own weight loss, and it was 6 years after they started struggling before they went to a healthcare practitioner…..And those 6 years are a missed opportunity."

He added: "Healthcare professionals are recognizing obesity as a disease but they believe the patients with obesity are not interested nor motivated to lose weight."

"We certainly noticed that discrepancy in what people with obesity say, and this is key in terms of why physicians or practitioners may or may not have initiated a conversation with a patient in front of them."

Consequently, Halford believes that "there are opportunities to improve obesity management."

"We need to improve education on the biological basis of obesity. Of course individual behavior is part of the equation but the biology of obesity we know is important in the etiology of the disease, as is the greater environment that biology is expressed in."

"And we need to get that message out, to stop putting it down to individual responsibility."

Furthermore, education needs to be improved around the clinical management of obesity, "because clearly both people with obesity and healthcare practitioners have little faith in some of the options that we have."

"Those options don't require hard work but do offer therapeutically beneficial outcomes," Halford emphasized, concluding that the frequency of follow-up appointments and referrals also needs to improve.

The study was sponsored by Novo Nordisk. All authors had travel expenses covered by Novo Nordisk to attend author meetings during the study. Caterson has reported receiving personal fees from Novo Nordisk (as chair of the ACTION-IO steering committee); grants from Novo Nordisk, Bristol-Myers Squibb, Pfizer, and Australian Eggs outside the submitted work; and lecture fees from Servier Laboratories and Novo Nordisk outside the submitted work. Halford has reported receiving honorarium from Novo Nordisk during the study. Ryan has reported being a paid advisor to Amgen, Bausch Health, Epitomee, Gila Therapeutics, IFA Celtic, Janssen, KVK Tech, Novo Nordisk, Phenomix, Quintiles, Real Appeal (United Health), ReDesign Health, Sanofi, and Scientific Intake; being a speaker for Novo Nordisk and Bausch Health; and holding equity positions with Gila Therapeutics, Phenomix, Xeon Bioscience, Epitomee, ReDesign Health, and Scientific Intake.

ECO 2019. Presented April 29, 2019. ACTION-IO study.

Diabetes Obes Metab. Published online April 29, 2019. Abstract

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