Health care providers' attitudes and counseling behaviors related to obesity

Abstract Background Obesity affects over 42% of the U.S. adult population, yet it remains undertreated. Many healthcare providers are biased in their perceptions and attitudes regarding obesity management and lack knowledge about how to treat it. Methods The authors analyzed the results of the 2021 DocStyles survey to examine primary care providers' treatment and perceptions of obesity. The sample consisted of primary care physicians and nurse practitioners/physician assistants. Questions assessed healthcare providers' attitudes and counseling behaviors related to obesity, including referrals, use of medical therapy, barriers to care, and perceived risk factors for obesity. Results 1168 primary care providers who treat obesity participated in the survey. About half of the providers reported referring patients for obesity treatment. Almost two‐thirds of providers had prescribed anti‐obesity medications in the last 12 months. Those who did not prescribe anti‐obesity medications reported a lack of familiarity with the medications or concerns about safety. Over three‐quarters of providers indicated at least one barrier to treating obesity. Over half of the providers reported that poverty and food insecurity contributed significantly to the high prevalence of obesity in communities of color. Conclusion Increased familiarity with anti‐obesity medications may improve treatment. Reasons for patients' low priority accorded to obesity care remain the focus of future research.

Previous work analyzing healthcare professionals' knowledge of obesity treatment has demonstrated a lack of familiarity with the clinical guidelines for obesity management. 2,5,6A previous survey of internists, family practitioners, obstetricians/gynecologists, and nurse practitioners conducted 5 years ago showed that only 16% of respondents indicated familiarity with the guidelines established by the U.S. Preventive Services Task Force and Centers for Medicare and Medicaid. 6Only 15% of respondents identified the correct indication to prescribe pharmacotherapy to treat obesity, and 20% of respondents indicated that long-term pharmacotherapy is unsafe. 6althcare professionals have cited time constraints, limited reimbursement, higher priority concerns, and lack of training in obesity management as the main barriers that prevent them from effectively treating their patients. 2,5ly limited research has focused on the rates of the use of pharmacotherapy to treat obesity.One large study of anti-obesity medication (AOM) use in 2.2 million adults across eight large healthcare organizations found that only 1.3% of eligible patients received a prescription for an AOM over a period of 6 years. 7other study of over 600 healthcare providers indicated that only 11% of providers recommended prescription weight loss medications to their patients as a treatment option. 2 Research also indicates that rates of pharmacotherapy use appear to be increasing among primary care providers, while pharmacotherapy use among OB-GYNs and nurse practitioners are much lower.The approval of multiple new medications for obesity treatment since 2012 is likely a catalyst for the observed increase in pharmacotherapy use among primary care providers. 8is study contributes to the literature by assessing the current practices and beliefs of primary care providers and evaluates practices and beliefs among primary care physicians (PCPs) and nurse practitioners/physician assistants (NP/PAs) regarding obesity counselling.This study reflects an ongoing inquiry into what primary care providers know about obesity care and identifies gaps in medical training and practice.

| METHODS
The Spring DocStyles 2021 survey instrument was developed by Porter Novelli with technical guidance provided by federal public health agencies and other non-profit and for-profit clients.DocStyles contained 102 questions, some with multiple subparts, which were designed to provide insight into health care providers' attitudes and counseling behaviors in regard to a variety of health issues and to assess their use of available health information sources.Demographic data were collected on each respondent's gender, race, work setting, practice location, and years of practice.Respondents were asked if they referred patients with obesity, and if so, to what types of specialists or services.Respondents also indicated whether they had prescribed medication to treat obesity in the past year, and if so, which medications.Respondents who had not prescribed medication were asked for their reasons for not prescribing.Respondents also reported their own barriers to treating obesity as well as the barriers they perceived among their patients to receive obesity treatment.
Respondents were also asked whether the COVID-19 pandemic influenced the rigor of their treatment and how the use of telemedicine to treat obesity impacted their treatment.Lastly, respondents were asked for their perspectives on how social determinants of health such as race and food insecurity may influence the prevalence of obesity in communities of color.The survey was conducted by SERMO, a global market research company.Efforts were made to enroll 1000 PCPs (a mix of family practitioners and internists), 250 OB/GYNs, 250 pediatricians, and 250 NP/PAs.

| Referral practices
The referral practices for obesity across provider types are shown in Table 2. Slightly over half of the total primary care providers surveyed reported that they referred patients for obesity treatment, while four out of ten said they provided counseling and treatment in their office.PCPs were more likely than NP/PAs to indicate that they provided in-office counseling and treatment.Of the primary care providers who referred patients with obesity, most referred to registered dieticians and obesity specialists; more than a third referred to community-based and face-to-face weight loss programs.There were no statistically significant differences in where PCPs and NP/PAs referred patients with obesity.

| Medical therapy practices
Medical therapy practices across providers are shown in Table 3.
Almost two-thirds of primary care providers indicated that they had prescribed a medication for obesity in the last 12 months.The most frequently selected drugs were Phentermine HCl, Contrave, and Saxenda.PCPs were more likely than NP/PAs to have prescribed medication overall, as well as each of the listed medications.While approximately one-third of providers indicated that they had not prescribed a medication for obesity in the last 12 months, nearly onethird of providers indicated that they had prescribed three or more medications in the last 12 months.The most frequently cited reasons for not prescribing medications for obesity were lack of familiarity with AOMs and concerns about drug safety.A similar percentage of PCPs and NP/PAs said they lacked familiarity with obesity medications.PCPs were almost two times more likely than NP/PAs to indicate concerns about drug safety and 21% of PCPs indicated that they thought medical therapy was not effective.

| Barriers to obesity treatment
Table 4 describes the respondents' perceived barriers to obesity treatment.Over three-quarters of the primary care providers surveyed indicated at least one barrier to treating obesity.The top three reported barriers were that their patients had other higher priority issues, they were not adequately compensated for treating obesity, or they did not have time to treat obesity.NP/PAs were less likely than PCPs to indicate that they are not adequately compensated for treating obesity.In addition to these barriers, 13% of primary care providers indicated that obesity is caused by patients themselves.NP/PAs were less likely than PCPs to select this response.Only two percent of providers indicated that obesity is not a disease.
When asked about barriers that their patients encountered when addressing their obesity, primary care providers were most likely to select inadequate insurance coverage and affordability of weight loss programs.Almost half of the providers indicated that the lack of recognition that obesity is a chronic disease was a patient barrier.There were no statistically significant differences between PCPs and NP/PAs regarding this question.

| Effects of COVID-19 on obesity treatment
The survey included questions on the impact of the COVID-19 pandemic on obesity treatment because several preliminary reports indicated that the pandemic resulted in an increase in the prevalence of obesity in children and adults, 9,10 although a larger study of adults failed to document an increase. 11The majority of primary care providers said that their treatment level was about the same now compared to before the COVID-19 pandemic (72%); 20% were treating more aggressively and 8% were treating less aggressively.The survey also asked respondents about their use of telemedicine to treat obesity because the pandemic contributed to an expansion of telemedicine services, and research suggests that patients who received obesity care via telemedicine during the pandemic experienced higher odds of weight loss compared to those who did not. 12Seventeen percent of primary care providers indicated that telemedicine made obesity care easier and 38% stated that it had no impact (38%); 27% of PCPs said it made obesity care more difficult.PCPs were slightly more likely than NP/PAs to use telemedicine to treat obesity (83% vs. 75%) and more likely to say that telemedicine did not impact obesity care (40% vs. 29%).

| Communities of color
Another key issue related to obesity is racial disparities in the prevalence of food insecurity in the United States, as food insecurity disproportionately affects racial and ethnic minority groups 13 and is significantly associated with increased adiposity. 14In 2018, households headed by Black or Hispanic parents experienced food security at a rate of 21% and 16%, respectively, compared to the national average of 11%. 15The racial and ethnic disparities observed with food insecurity have only been exacerbated by the COVID-19 pandemic.In 2020, approximately 25% of families with school-age children reported food insecurity in the last 30 days; this rate was 40% among families in which the parents were either Black or Hispanic. 16Eightyfive percent of providers thought that poverty and food insecurity contributed "somewhat" or "a lot" to the high prevalence of obesity in communities of color, while only 50% of providers thought that stress caused by racism or discrimination contributed "somewhat" or "a lot" to the issue.Many providers also thought that in communities of color, lack of awareness of obesity as a disease (77%) and cultural norms that accept increased body size (80%) also contributed "somewhat" or "a lot" to high obesity prevalence.No statistically significant differences were found between PCPs and NP/PAs in their views on contributors to high obesity prevalence in communities of color.

| Perspective on obesity etiology
Along with individually reviewing the results of the survey question "My barriers to treating obesity include…", the authors explored whether a provider's response to this question was related to their responses to other survey questions.Of particular interest was the response option, "Obesity is caused by patients themselves."Thirteen percent of participants selected this response.Primary care physicians who thought that patients with obesity were responsible for their obesity were more likely to think that obesity was not a disease (8% vs. 1%).When asked about reasons for not prescribing medication for obesity, participants who reported that obesity was caused by patients themselves were more likely to select "concern about drug safety" (60% vs. 39%) and "obesity doesn't require medical therapy" (15% vs. 2%).They were also more likely to select "Medical therapy is not effective" (30% vs. 16%).In terms of perceived patient barriers, participants who felt that obesity was caused by patients themselves were more likely to report that the lack of recognition that obesity is a chronic disease is a barrier that patients encounter (59% vs. 47%).

| Prescribers versus non-prescribers
Comparisons of the referral practices, provider barriers to treatment, and perceived patient barriers to treatment among prescribers versus non-prescribers of AOMs are shown in Table 5. Providers who had prescribed AOMs in the last 12 months were more likely to provide obesity counseling and treatment in the office, compared to those who had not prescribed AOMs in the last 12 months.Prescribers were also more likely to refer patients with obesity to faceto-face weight loss programs and digital weight loss programs compared to non-prescribers.Prescribers were more likely to indicate that inadequate insurance coverage and affordability of commercial/digital weight loss programs were barriers that their patients encountered when addressing their obesity.
Providers who had not prescribed AOMs in the last 12 months were more likely to select "I do not have anywhere to refer patients" than prescribers.Non-prescribers were also more likely to indicate that they did not have time to treat obesity and were not up to date on obesity treatments.First, the analysis of referral practices of the survey respondents revealed that of those who treat obesity, over half of the providers refer patients with obesity.Of the providers who refer patients, the majority refer patients to registered dieticians or nutritionists as well as obesity specialists.When asked about their own barriers to treating obesity, the most common answer was "patients have other

| DISCUSSION
higher priority issues"; approximately half of the providers selected this response.The most frequently cited patient barriers were "Inadequate insurance coverage for obesity care" and "Affordability of commercial/digital weight loss programs," and about half of the respondents responded that "Lack of recognition that obesity is a chronic disease" as a patient barrier.
Comparison of providers who had prescribed AOMs versus those who had not revealed key findings on obesity treatment practices and attitudes among primary care providers.Prescribers of AOMs were significantly more likely to provide treatment and counseling in their office, while non-prescribers were significantly more likely to refer patients for obesity treatment.Non-prescribers were also more likely than prescribers to indicate that they did not have anywhere to refer patients, they lacked the time to treat obesity, were not up to date on obesity treatments, and indicated concerns and lack of knowledge about drug safety.All these findings reflect the need for increased awareness of obesity treatment resources and training.
The findings that almost 50% of providers lack familiarity with drug therapy, and almost as many PCPs concerned about drug safety, present significant challenges to the adequacy of care.The FDA approval of semaglutide and the pending approval of tirzepatide offer new and highly effective options with minimal side effects for the treatment of obesity.For example, 35% of patients in a semaglutide trial and 63% of patients in a tirzepatide (15 mg dose) trial lost ≥20% of their body weight. 17,18These findings emphasize the need for inclusion of obesity in medical school curricula, and training in the use of AOMs for interns, residents, and practicing PCPs.The lack of patient coverage for obesity as well as the lack of reimbursement for obesity care represent additional barriers to the delivery of care. 19xty-five percent of the sample prescribed medication for obesity.A limitation of this finding is that this statistic does not indicate the extent to which these prescriptions are filled by patients.
According to the findings of a large study of AOM use, only 1.3% of patients with obesity filled an AOM prescription, and only a small proportion of prescribers were responsible for the majority of filled prescriptions. 7This observation suggests a gap in the treatment process and frequent failure to get patients to follow-through with their prescribed treatment.The high rate of respondents stating that they prescribed pharmacotherapy may also suggest that this sample is biased compared to the general population of providers.In future studies, data on the number of providers prescribing AOMs and the rate of filled prescriptions per provider would provide essential insight into patient adherence as a function of providers' quality of obesity counselling and explanation of drug therapies to their patients.
The majority of primary care providers reported that their treatment level was about the same now compared to before the COVID-19 pandemic.A possible explanation for this result is the lack of significant changes in obesity prevalence among adults as a result of the COVID-19 pandemic.
practice was 16 years (M = 16.4,SD = 9.7).The majority of respondents were White, with NP/PAs having the largest percentage of White respondents.Men made up 61% of the sample and were more likely to be PCPs.Women made up the majority of the NP/PA respondents.Most providers worked in a group outpatient practice or clinic and a majority worked in a suburban setting.
This analysis of the results of the 2021 DocStyles survey illuminated multiple key findings.The differences in treatment practices between PCPs and NP/PAs may reflect differences in training and competencies by provider type.Because obesity affects over 42% of U.S. adults, understanding the attitudes and barriers related to treatment is a critical concern.Furthermore, understanding the attitude and practices of the frontline clinicians who encounter patients with obesity daily will help to target the needs for further education and training.

N = 1168 N = 954 N = 214
Characteristics of survey respondents.Referrals for obesity across providers.
T A B L E 1 a Multiple selections.*pvalue <0.05 in difference in response between providers.SMITH ET AL.
Which of these medications have you prescribed for obesity in the last 12 months?a T A B L E 3 Medical therapy for obesity across providers.a Multiple selections.b Percent among those who have not prescribed medication; multiple selections.*p value <0.05 in difference in response between providers.504 -SMITH ET AL.T A B L E 4 Barriers to obesity treatment.a Multiple selections.*p value <0.05 in difference in response between providers.
Responses stratified by prescribers and non-prescribers of obesity medication.
11Preliminary findings on the impact of the COVID-19 pandemic on obesity treatment indicate that behavioral weight-management interventions do not differ significantly in T A B L E 5 a Multiple selections.*p value <0.05 in difference in response between prescribers versus non-prescribers.