Obesity Management: Australian General Practitioners’ Attitudes and Practices
School of Health Sciences, Deakin University, 221 Burwood Highway, Burwood 3125, Australia. E-mail: email@example.com
Objectives: To document general practitioners’ (GPs) attitudes and practices regarding the prevention and management of overweight and obesity.
Research Methods and Procedures: A cross-sectional survey of a randomly selected sample of 1500 Australian GPs was conducted, of which 752 questionnaires were returned. The measures included views on weight management, definitions of success, views regarding the usefulness of drugs, approaches to and strategies recommended for weight management, and problems and frustrations in managing overweight and obesity.
Results: GPs view weight management as important and feel they have an important role to play. Although they consider themselves to be well prepared to treat overweight patients, they believe that they have limited efficacy in weight management and find it professionally unrewarding. GPs view the assessment of a patient's dietary and physical activity habits and the provision of dietary and physical activity advice as very important. The approaches least likely to be considered important and/or least likely to be practiced were those that would support the patient in achieving and maintaining lifestyle change.
Discussion: There remains considerable opportunity to improve the practice of GPs in their management of overweight and obesity. Although education is fundamental, it is important to acknowledge the constraints of the GPs’ existing working environment.
Overweight and obesity are significant and growing public health concerns, requiring a spectrum of activity encompassing both prevention and treatment that focuses on individual behavior as well as environmental and structural change (1). The general practitioner (GP) has been identified as an important potential contributor to treatment and prevention of overweight and obesity, in part, because this occupation has a unique position. In Australia, for example, GPs have contact with 80% of the population in any year (2), are the most frequently used source for information about weight control (3), and are perceived to be the most reliable formal source of information (4). In addition, there is evidence that advice from a doctor may prompt attempts at weight loss (5) and encourage other health-promoting behaviors (6).
Among medical practitioners, there is a high awareness of obesity as a medically relevant issue, a willingness to view weight management as an appropriate part of their responsibilities, and an interest in further skills training (7). There are also data showing that GPs rate themselves as “quite effective” as weight loss agents (8) and that they consider themselves to be influential in getting patients to change their diets (9). Although collectively these findings suggest that GPs will provide an environment that supports high-quality weight management interventions, there are a range of factors that limit medical practitioners’ capacity to deliver such interventions.
Obesity management is significantly influenced in the first instance by low levels of obesity identification (10) and a reluctance to manage weight when there are no comorbidities (9), or when the patient is overweight as opposed to obese (7). Furthermore, health professionals, including GPs, hold negative attitudes toward their overweight and obese patients (6,7,11,12,13,14,15). It has been suggested that such attitudes can significantly impede the practitioner's levels of involvement and interaction (13,16,17). Other studies have shown that GPs see their low levels of relevant knowledge and skills as an impediment to more effective weight management practice (7,9,18,19), and Cade and O'Connell (13) found that a range of predictors of improved treatment success did feature poorly in GPs’ practice. It is also interesting to note that levels of nutrition knowledge in GPs is low (18) and that current practice in the promotion of exercise is significantly different from desirable practice (20).
Although GPs are potentially well placed to play a key role in the prevention and management of obesity, the existing data suggest that GPs’ practice in this area may be constrained because they do not possess appropriate skills. However, at present only limited information regarding GPs’ attitudes and practices regarding the prevention and management of overweight and obesity is available. A more detailed understanding of these issues is necessary to determine how best to facilitate GPs’ contribution to addressing the epidemic of obesity. The aim of this study is to document GPs’ attitudes and practices in relation to the prevention and management of overweight and obesity.
Research Methods and Procedures
The sampling frame for this study comprised GPs who were members of the Royal Australian College of General Practitioners (RACGP) or whom were listed in their database. This database comprises approximately 24,000 GPs, including trainees, vocationally registered GPs, retired GPs, and other medical practitioners who have contacted the RACGP for use of its services. A random sample of 1500 GPs was drawn from the RACGP database. The sample was randomly divided into two equal groups (each of 750 GPs). Half the sample received one version of the survey questionnaire; the other half received the other version. As described below, it was necessary to administer two versions of the questionnaire to reduce respondent burden.
Two self-completion questionnaires were developed for this study (described below). A mail-survey technique was used to administer the questionnaires. Each subject received a cover letter, a copy of the appropriate questionnaire, a consent form, and a return envelope with postage paid. To improve response, a complimentary copy of The Heart Foundation Cookbook was offered to the first 100 GPs who returned completed questionnaires. Three weeks after the initial mailing, nonrespondents received a reminder letter, together with a second copy of the appropriate questionnaire and a return envelope with postage paid.
The questionnaire was developed by a review of literature in the field and was based on a questionnaire that examined dietitians’ attitudes and practices to obesity management (21). The questionnaires were pilot-tested with 24 GPs for scope, length, and clarity. Based on this, it was clear that only a short questionnaire would be completed by GPs. Therefore, two versions of the questionnaire were created. One focused on GPs’ attitudes to managing and preventing overweight and obesity (the “attitudes” questionnaire), and the other examined GPs’ practices regarding the management and prevention of overweight and obesity (the “practices” questionnaire). Each questionnaire was designed to be completed in less than 10 minutes. The items included in each questionnaire are described below.
These questions were identical in both questionnaires. Questions were included regarding age, sex, postal code(s) of the practice(s) within which the GP works, description of the practice (i.e., number of GPs employed), current work status, number of patients seen each week, and types of allied health professionals working as part of the practice.
Views on Weight Management.
The “attitudes” questionnaire included 10 statements designed to examine GPs’ perception of patients’ ability to lose weight, when a GP should offer intervention, and the perceived role of the GP (see Table 2). Both questionnaires included two statements to assess whether GPs felt prepared enough to treat overweight patients and obese patients (see Table 2). Participants were asked to indicate their level of agreement with each statement on a five-point Likert scale: “strongly disagree,” “disagree,” “neutral,” “agree,” and “strongly agree.”
Table 2. Views regarding various aspects of weight management (n = 386)
|Aspect||Strongly disagree||Disagree||Neutral||Agree||Strongly agree|
|Adults with a body weight within the healthy range (BMI of 20–25 kg/m2) should be encouraged by GPs to maintain their weight.||1||3||10||60||27|
|Most adults with a body weight above the healthy range (BMI >25 kg/m2) should be offered treatment for weight loss.||1||11||12||62||15|
|Only adults who are obese (BMI >30 kg/m2) should be offered treatment for weight loss.||11||54||6||19||10|
|Treatment of overweight should only be offered when other risk factors, such as type 2 diabetes or hypertension are present.||23||61||3||6||8|
|Small weight losses can produce important medical benefits.||0||2||10||70||18|
|Only a small percentage of people who are overweight can reduce their weight and maintain that loss.||4||34||8||44||11|
|GPs’ time would be best spent in this area by preventing overweight in the first instance.||1||13||27||50||9|
|Counseling patients who need to lose weight is generally professionally rewarding.||7||32||20||36||5|
|The best role for a GP is to refer overweight and obese patients to other professionals rather than attempt to treat them.||15||62||14||9||1|
|I would only offer advice regarding weight control when a patient requests it.||16||72||5||6||1|
|I am professionally well prepared to treat patients who are overweight (BMI 25–30).*||2||8||20||58||12|
|I am professionally well prepared to treat patients who are obese (BMI >30).*||3||14||25||47||11|
Definitions of Success.
The “attitudes” questionnaire included six statements regarding a range of outcomes for overweight/obesity management (seeTable 3). GPs were asked to indicate the importance of each outcome on a three-point response scale: “not important,” “quite important,” and “very important.”
Table 3. Views of the importance of various outcomes as measures of success in weight management (n = 373)
|Outcome||Not important||Quite important||Very important|
|Improvement in clinical indicators of health and disease (e.g., waist-to-hip ratio, blood pressure, lipid profile)||1||36||64|
|Adoption of improved food and exercise habits irrespective of weight loss||0||41||59|
|Improved body image and self confidence irrespective of weight loss||3||58||39|
|Small weight loss that is sustained over time||3||60||36|
|Maintenance of present body weight over time||9||56||35|
|Weight loss to the healthy range (BMI 20–25 kg/m2)||10||63||28|
Views Regarding the Use of Drugs.
The “attitudes” questionnaire included two questions, which asked “How useful do you find drugs in the management of overweight (body mass index [BMI], 25 to 30 kg/m2)?” and “How useful do you find drugs in the management of obesity (BMI, >30 kg/m2)?” The response categories provided were: “not at all useful,” “of some use,” “quite useful,” “useful,” and “very useful.”
Approaches to Weight Management.
The “practices” questionnaire included a series of 11 statements (see Table 4) that assessed GPs’ perceptions of the importance of a series of weight management approaches and the frequency with which they performed each approach. GPs indicated on a three-point response scale how important each option was (“not important,” “quite important,” and “very important”) and indicated whether they usually did this.
Table 4. GPs’ perceptions of the importance of different approaches to weight management and use of these approaches (n = 341)
|Approach||Not important||Quite important||Very important||Usually done (%)|
|Assessing patients’ weight history||1||60||39||83|
|Assessing patients’ dietary habits||1||46||54||88|
|Assessing patients’ physical activity habits||0||41||59||94|
|Assessing patients’ readiness for change at first contact||13||54||32||62|
|Assessing the home environment for supportive structures/partner||8||71||21||48|
|Assessing patients’ expectations of weight management/loss||2||60||38||78|
|Assessing patients’ definitions of successful outcomes for weight management||5||60||35||68|
|Seeing patients together with a spouse or significant other||38||55||7||14|
|Referring patients to other health care professionals||17||68||16||65|
|Reviewing your patients’ progress for more than 6 months||2||59||39||85|
|Reviewing your patients’ progress for more than 2 years||8||70||22||53|
Strategies Recommended for Weight Management.
The “practices” questionnaire included a series of 13 specific weight management strategies (see Table 5). Participants indicated on a three-point response scale how important they considered each strategy to be (“not important,” “quite important,” and “very important”) and indicated whether they usually advised patients to employ each of these strategies.
Table 5. GPs’ perceptions of the importance of different weight management advice and provision of this advic (n = 345)
| ||Not important||Quite important||Very important||Usually done (%)|
|Specific advice to eat fewer kilocalories||17||45||38||78|
|Specific advice to reduce total fat intake||1||20||79||98|
|Specific advice to reduce dairy foods||36||47||17||54|
|Specific advice to reduce red meat||39||48||13||50|
|Specific advice to reduce alcohol||3||54||44||93|
|Specific advice to increase bread and cereal consumption||8||48||44||83|
|Specific advice to increase fruit and vegetable consumption||1||31||66||96|
|General advice to do more exercise or be more active||<1||15||85||99|
|Advice to incorporate low-intensity, long duration activity such as walking, into present lifestyle||1||21||78||98|
|Practical advice regarding shopping and cooking to achieve dietary goals||7||60||33||27|
|Advice to keep an eating awareness diary||25||63||13||27|
|Advice to join a commercial slimming group||73||24||3||13|
|Advice to join a community slimming group||42||53||5||41|
Problems and Frustrations.
All participants were asked the following open-ended question: “What is the major problem or frustration you have experienced in treating/managing overweight and obesity?”
The questionnaires were hand-checked for completeness and coded before data entry. One investigator coded all responses to the open-ended question, and coding categories developed as questionnaires were inspected. In dealing with responses to open-ended questions, our aim was to group them into domains representing common issues. Statistical analysis was performed using SPSS software (22). Because the primary aim of this study was to describe attitudes and practices of GPs, the data were examined by simple frequency counts.
Profile of Participants
Of the 750 “attitudes” questionnaires distributed, 389 were returned complete or partially complete and 33 were returned as undeliverable, representing a response rate of 54%. Of the 750 “practices” questionnaires, 363 were returned complete or partially complete and 32 were returned as undeliverable, representing a response rate of 51%. Table 1 presents a profile of the GPs who participated in the surveys. There were no notable differences between the profiles of the GPs who participated in the two versions of the survey. The distribution of male and female GPs that responded to this study were similar to that of GPs across Australia. However, GPs aged under 35 years were slightly under-represented in the sample, whereas GPs between 55 and 64 years were slightly over-represented (23).
Table 1. Characteristics of GPs participating in the “attitudes” and “practices” surveys
| ||“Attitudes” (n = 389)||“Practices” (n = 363)|
|Sex|| || |
| || || |
|Age (years)|| || |
|65 or over||10.5||9.9|
| || || |
|Work status|| || |
| || || |
|Practice type|| || |
|2–3 full-time equivalent GPs||38.1||40.8|
|4 or more full-time equivalent GPs||33.8||29.9|
| || || |
|Number of patients seen per week|| || |
Views on Weight Management
Participants’ views regarding various aspects of weight management are presented in Table 2. Almost 90% of GPs felt they should encourage adults in the healthy weight range to maintain their weight. Over three-quarters agreed that most overweight adults should be offered treatment, less than 30% felt that only the obese should be offered treatment, and 15% agreed that treatment should only be offered to patients with other risk factors. Almost all GPs acknowledged there are important medical benefits associated with small weight losses.
Approximately half of the GPs surveyed held the view that relatively few people can lose weight and maintain this loss. Consistent with this, just over half agreed their efforts would be best spent trying to prevent overweight, and less than half described weight loss counseling as rewarding. Nevertheless, most disagreed the best role for them was to refer patients to other health professionals, and less than one in ten reported offering weight advice only when requested. A majority of GPs (72%) felt they were sufficiently prepared to treat patients who were overweight, with over half of the GPs describing themselves as prepared enough to treat obesity.
Definitions of Success
GPs’ views of the importance of various outcomes as measures of success are summarized in Table 3. The improvement of clinical indicators of health was nominated as “very important” by almost two-thirds of the survey participants, followed closely by the adoption of improved food and exercise habits. Improved body image and self-confidence ranked third, nominated by 40%, and a similar proportion felt small weight loss and weight maintenance were also very important measures of success. Weight loss to the healthy weight range ranked as the least important measure of success.
Approaches to Weight Management
GPs’ approaches to weight management are summarized in Table 4. More than half viewed assessment of their patients’ dietary and physical activity habits as “very important.” Between 30% and 40% of participants believed it was “very important” to assess patients’ weight history, expectations of weight loss, definitions of successful outcomes, and readiness for change. Fewer than one in four GPs felt it was “very important” to assess the home environment for supportive structures, to refer patients to other professionals, or to see patients with a significant other. In fact, almost 40% of participants held the view that it was not important to see patients with a spouse or significant other. Although relatively few GPs held the view that it was “not important” to review their patients’ progress, only 39% described it as “very important” to do so for more than 6 months, and just 22% saw it as “very important” to review progress for more than 2 years.
Generally the respondents’ self-reported weight management practices reflected their views on their relative importance. Therefore, almost all reported they “usually” assess physical activity habits, dietary habits, and weight loss history. Although less than 40% of GPs saw it as “very important,” 85% reported they “usually” reviewed progress for more than 6 months. For almost all the other weight management approaches listed, over half of the respondents reported they “usually” practiced them. Seeing patients with a spouse or significant other was the only exception, nominated by less than one in six GPs.
Views Regarding the Use of Drugs
Relatively few GPs described drugs as useful for managing overweight patients: 42% felt drugs were “not at all useful,” 47% described them as “of some use,” 6% as “quite useful,” and 5% as either “useful” or “very useful.” The GPs perceived a greater role for drugs in managing obese patients. Only 31% described them as “not at all useful,” 52% as “of some use,” 10% as “quite useful,” and 7% as either “useful” or “very useful.”
Strategies Recommended for Weight Management
Over three-quarters of GPs considered advice to increase activity, to incorporate low-intensity activity of a long duration into lifestyle, and to reduce total fat intake as “very important” (Table 5). Two-thirds considered it to be “very important” to advise increased fruit and vegetable consumption for weight management. The vast majority of GPs stated they “usually” gave their patients this advice. Although less than half of the GPs stated that advice to reduce caloric and alcohol intake and increase bread and cereal consumption was “very important,” over three-quarters stated they usually advised their patients to do so. Advice to eat less red meat and dairy foods was not perceived as very important, however, one in two GPs usually gave this advice.
Problems and Frustrations Experienced by GPs
The major problems or frustrations participants had experienced treating or managing overweight and obesity are listed in Table 6. The most common related to patients’ lack of compliance, low motivation on the part of the patient, and lack of success or progress in relation to weight loss.
Table 6. Most common problems/frustrations experienced by GPs in managing overweight and obese patients (n = 752)
|Poor compliance by patients/inability to make lifestyle changes||33|
|Patients lack motivation/are unable to maintain motivation||15|
|Lack of success in reducing weight and/or lack of progress on part of patient||13|
|Patients unable to maintain weight loss and/or tend to regain weight||12|
|Client has no long-term commitment and/or lacks interest||11|
|Patients deny their actual habits||7|
|Time constraints/time consuming||6|
|Patients have unrealistic expectations and/or expect immediate weight loss||5|
|Underlying emotional or psychological issues||5|
This study examined contemporary attitudes and current practice of GPs in weight management. As such, this work provides unique and valuable insights while adding to the existing literature in this area. We found that many GPs hold strong positive views about their roles and responsibilities in the area of obesity management and prevention. There was strong support for the view that they have an obligation to offer weight management to those who are already overweight or obese, and that this should not be limited only to the most obese, nor only to those who have associated comorbidities. General Practitioners’ commitment to weight management was also supported in part by a strong sense of their competence, although, as earlier studies have shown (7,9), this diminished as a patient progressively became obese. It is also noteworthy that around half of all GPs’ had low expectations of the effectiveness of weight management with less than half describing weight management as professionally rewarding. Together, these findings highlight the importance of taking steps to provide GPs with the improved knowledge and skills necessary to manage overweight and obesity.
Professional dissatisfaction in weight management has been reported previously for other health professionals (11,21). It has been suggested that a significant source of this dissatisfaction is the setting of unrealistic and unachievable weight loss goals (16). Given that the GPs in this survey viewed weight loss to the ideal weight range as the least important outcome of management, it appears unlikely that the physicians’ unrealistic expectations are the principle cause of professional dissatisfaction. However, other cited barriers to undertaking weight management, such as perceived lack of patient interest and expected patient nonadherence to physician advice (8,9), were reflected in these GPs’ frustrations with their patients and may be related to the high levels of dissatisfaction.
The confidence that GPs had in their ability to manage weight was not fully supported by the existing literature, nor by their own description of their current approaches to weight management. For instance, assessment of a patient's dietary and physical activity habits, and the provision of dietary and physical activity advice were viewed as very important, and GPs reported that they usually undertook them. However, although these approaches were considered to be important and were used by the GPs, studies suggest that training in these areas remains inadequate (18,24). Furthermore, the approaches least likely to be considered important and/or least likely to be practiced were those that would support the patient in achieving and maintaining lifestyle change (i.e., long-term follow-up, promotion of self-monitoring, promotion of opportunities for social support, or referral to weight management groups) (25,26,27,28).
The weight management approaches considered to be important, and subsequently undertaken, may reflect GPs’ established domains of experience and confidence in practice. Documentation of patient history and the provision of didactic (prescriptive) advice are likely to be more familiar to GPs than is the use of cognitive-behavioral therapies. In addition, time constraints may also affect GPs capacity to employ cognitive approaches, to engage the family/spouse, and to allocate time to long-term follow-up. Even so, this would only explain the fact that these approaches are not employed, and does not account for the fact that they were considered to be unimportant. The apparent disregard of the importance of social supports to the success of weight management strategies cannot be reasonably explained by time constraints and suggests a lack of knowledge of the significance of social support in this area.
Although GPs’ commonly employ those aspects of best practice in weight management that relate to history taking and the prescription of advice, they appear to undervalue and underutilize aspects of best practice that seek to promote and support lifestyle change, such as the use of cognitive behavioral therapies. However, GPs consider weight management to be important, and there remains considerable opportunity to improve the practice of GPs in their management of overweight and obesity. Although education is fundamental, it is important to acknowledge the constraints of the GPs’ existing working environment. Because this study achieved only a modest response and respondents were potentially more interested and/or confident in weight management than nonrespondents and may have over-reported their use of the various approaches to weight management, these findings probably represent a “best case scenario” of GP involvement in weight management in Australia. Further research should be undertaken to explore the effectiveness of a range of preventive and treatment strategies that may be employed by GPs within their existing practice.
This study was supported by funding from the Heart Foundation of Australia (Victorian Division). David Crawford was supported by a National Health and Medical Research Council Public Health Research Fellowship, and a Nutrition Research Fellowship from the National Heart Foundation of Australia. We thank the Royal Australian College of General Practice for providing assistance with accessing Australian general practitioners, and particularly the general practitioners who participated in the study.