ACTION APAC: Understanding perceptions, attitudes and behaviours in obesity and its management across south and Southeast Asia

To identify perceptions and attitudes among people with obesity (PwO) and healthcare professionals (HCPs) toward obesity and its management in nine Asia‐Pacific (APAC) countries, a cross‐sectional online survey was conducted among adult PwO with self‐reported body mass index of ≥25 kg/m2 (≥27 kg/m2, Singapore), and HCPs involved in direct patient care. In total, 10 429 PwO and 1901 HCPs completed the survey. Most PwO (68%) and HCPs (84%) agreed that obesity is a disease; however, a significant proportion of PwO (63%) and HCPs (41%) believed weight loss was the complete responsibility of PwO and only 43% of PwO discussed weight with an HCP in the prior 5 years. Most respondents acknowledged that weight loss would be extremely beneficial to PwO's overall health (PwO 76%, HCPs 85%), although nearly half (45%) of PwO misperceived themselves as overweight or of normal weight. Obesity was perceived by PwO (58%) and HCPs (53%) to negatively impact PwO forming romantic relationships. HCPs cited PwOs' lack of interest (41%) and poor motivation (37%) to lose weight as top reasons for not discussing weight. Most PwO (65%) preferred lifestyle changes over medications to lose weight. PwO and HCPs agreed that lack of exercise and unhealthy eating habits were the major barriers to weight loss. Our data highlights a discordance between the understanding of obesity as a disease and the actual behaviour and preferred approaches to manage it among PwO and HCPs. The study addresses a need to align these gaps to deliver optimal care for PwO.


Summary
To identify perceptions and attitudes among people with obesity (PwO) and healthcare professionals (HCPs) toward obesity and its management in nine Asia-Pacific (APAC) countries, a cross-sectional online survey was conducted among adult PwO with self-reported body mass index of ≥25 kg/m 2 (≥27 kg/m 2 , Singapore), and HCPs involved in direct patient care.In total, 10 429 PwO and 1901 HCPs completed the survey.Most PwO (68%) and HCPs (84%) agreed that obesity is a disease; however, a significant proportion of PwO (63%) and HCPs (41%) believed weight loss was the complete responsibility of PwO and only 43% of PwO discussed weight with an HCP in the prior 5 years.Most respondents acknowledged that weight loss would be extremely beneficial to PwO's overall health (PwO 76%, HCPs 85%), although nearly half (45%) of PwO misperceived themselves as overweight or of normal weight.Obesity was perceived by PwO (58%) and HCPs (53%) to negatively impact PwO forming romantic relationships.HCPs cited PwOs' lack of interest (41%) and poor motivation (37%) to lose weight as top reasons for not discussing weight.Most PwO (65%) preferred lifestyle changes over medications to lose weight.PwO and HCPs agreed that lack of exercise and unhealthy eating habits were the major barriers to weight loss.
Our data highlights a discordance between the understanding of obesity as a disease and the actual behaviour and preferred approaches to manage it among PwO and HCPs.The study addresses a need to align these gaps to deliver optimal care for PwO.
adult, attitudes, cross-sectional study, health knowledge, obesity, weight loss

| INTRODUCTION
The burden of obesity is profound, impacting an estimated 1 billion people worldwide in 2020. 1 Between 1975 and 2016, the prevalence of obesity has increased by almost three times and is expected to increase further. 1 According to the World Obesity Federation (WOF), 24% of the world's population is expected to be living with obesity by 2035, up from 14% in 2020. 1,2In the Asia-Pacific (APAC) region, which comprises 60% of the world's population, two out of five adults are living with overweight and obesity, with the latter contributing to an annual economic burden of USD 166 billion. 3pid changes in the economic status and urbanization of many lower-and middle-income countries across the APAC region, along with changes in lifestyle related to diet and physical activity, have contributed to the increased burden of overweight and obesity. 4,57][8] Despite the growing understanding that obesity is a complex and progressive chronic disease, the existence of established international guidelines on obesity management, and the increasing availability of effective obesity treatment in recent years, a substantial proportion of PwO are struggling to lose and maintain weight loss (WL), and HCPs and PwO are relying solely on lifestyle modifications to achieve WL goals. 9This reflects a poor understanding of the powerful impact of underlying genetic and biological drivers of obesity. 10ychosocial and cultural beliefs, as well as healthcare infrastructure, can influence perceptions and attitudes regarding obesity and behaviours in obesity management. 11The APAC region has its unique cultural, social and environmental characteristics and healthcare infrastructure, which may distinguish beliefs, attitudes and behaviours in this region from those observed elsewhere in the world.It is important to understand HCP and PwO interactions to encourage a cooperative HCP-patient relationship to provide optimal care and facilitate attempts by PwO to attain a healthy weight.With obesity prevalence rising rapidly in this region, there is an urgent need to ensure effective obesity care for PwO in this region.

| Study design
The ACTION APAC study was a cross-sectional, non-interventional, descriptive study that collected data through an online survey between 14-April-2022 and 23-May-2022 across nine countries, including Bangladesh, India, Indonesia, Malaysia, Pakistan, Philippines, Singapore, Thailand, and Viet Nam.The inclusion of these countries in the survey was based on their representation of the diverse cultural and socioeconomic (healthcare setting/infrastructure) landscape in the region.The countries included are a subset of those that fall under the general descriptor of 'APAC' as categorized by the World Obesity Federation. 1 Other countries, such as Australia, Japan and South Korea, participated in the previously conducted ACTION International Observation (IO) study 6 and thus were not included in the ACTION APAC study.The survey was conducted by a third-party vendor (KJT Group, Inc., Rochester, NY, USA) through online panels.
The study received an exemption from the WCG Institutional Review Board, as the study contained adequate protections for the privacy of subjects and to maintain confidentiality of data.

| Study cohorts
The study aimed to achieve a total of approximately 12 400 completed surveys: 10 500 among PwO and 1900 among HCPs.Adults (aged ≥18 years) residing in participating countries were eligible to participate if they had a body mass index (BMI) of ≥25 kg/m 2 (≥27 kg/m 2 for Singapore) based on self-reported height and weight.
Participants were excluded if they were pregnant, previously participated in the survey, were involved in intense fitness and body building programs, or experienced significant unintentional WL in the past 6 months.HCPs included in the study were medical practitioners from participating countries with two or more years in practice who had seen ≥100 patients (with ≥10 PwO) in the past month, and who spent at least 50% of their time in direct patient care.PwOs and HCPs with previous study participation or language barriers precluding adequate understanding or cooperation with the study were excluded.Sample sizes were selected to balance statistical power, recruitment feasibility, and cost.PwO sample sizes for each country were targeted to achieve 2%-3% margin of error around a proportion estimate of 50%, with the margin of error calculated from a standard normal (Z-) distribution with z = 1.96, or approximately a 95% level of confidence.Sample sizes in some countries were reduced slightly based on population and recruitment considerations.

| Survey design and data collection
Survey questions were based on the questionnaires from the three previous ACTION studies (United States, 7 Canada, 8 and IO 6 ) and modified for the APAC region based on input from a panel of scientific experts in the region.Distinct questionnaires were developed for PwO (Appendix A) and HCPs (Appendix B).The surveys were translated into languages appropriate for each country.The surveys collected data on perceptions, behaviours, and awareness of PwO and HCPs related to obesity and obesity management.Questions on weight stigma were also included to ensure coverage of this important topic and understand its implications in healthcare.The survey questions were designed to ensure every question was answered so there were no missing data.
In the PwO questionnaire, participants were asked about their: Data were collected in the survey using Decipher Survey Software (Focus Vision Worldwide Inc.), which was administered through online panels, telephone and in-person interactions as per countryspecific requirements.The survey was conducted in compliance with the European General Data Protection Regulation (GDPR).

| Data analysis
Analysis of de-identified data was conducted by KJT Group using vari-

| Demographics
A total of 10 429 PwO and 1901 HCPs completed the survey.Among PwO, there was equal gender representation with a mean age of 38 (SD = 12.7) years, and the majority (51%) had Class I obesity (BMI: 25-29.9kg/m 2 or 27-31.9kg/m 2 for Singapore).Most HCPs were males (73%), had a mean of 11 (SD = 5.7) years of experience and spent 72% of their professional time in direct patient care.Almost half of the HCPs (48%) were obesity specialists (i.e., ≥50% of patients seen primarily for obesity), considered themselves as experts in obesity (76%), and received advanced training in obesity (72%).See Table 1 for the characteristics of the study sample.

| Perceptions and attitudes toward obesity and weight stigma
A total of 68% of PwO and 84% of HCPs agreed that obesity is a chronic disease (Figure 1).Additionally, 76% of PwO and 80% of HCPs believed that obesity has an extreme impact on a person's overall health.WL of 5%-10% of body weight was considered extremely beneficial to the health of PwO by 76% of PwO and 85% of HCPs (Figure 1).However, a large proportion of PwO (63%) considered themselves responsible for their WL and less than half of PwO (42%) expected active contribution from HCPs toward their WL efforts (Figure 1).Most HCPs (72%) acknowledged their responsibility to help PwO in their WL efforts, but a substantial proportion of HCPs (41%) considered WL to be completely the responsibility of PwO (Figure 1).
Just over half of PwO (53%) reported that they were motivated to lose weight, whereas 64% of HCPs thought PwO were motivated to lose weight (Figure 1).PwO expressed a desire to be more fit or in better shape, to feel better physically, and wanting to be more confident as the top reasons for wanting to lose weight (Table 2, see Figure S1 for the full list of motivators).HCPs believed that wanting to feel better physically, having general health concerns, and wanting to be more confident were the top motivators for PwO to lose weight (Table 2).
More than half of all PwO and HCPs agreed that a lack of exercise, unhealthy eating, and an inability to control hunger were among the top barriers for PwO to lose weight (Table 2, see Figure S2 for the full list of perceived barriers).Notably, about half of PwO (46%) and HCPs (51%) also believed PwOs' genes are a barrier to WL (Figure S2).
Both PwO and HCPs believed that having obesity made it harder for PwO to form a romantic relationship (58% and 53%, respectively), get a job (53% and 39%), and be successful in the workplace (49% and 35%) (Figure 2).Both groups also viewed having overweight as having a somewhat or very negative impact on others' perception of them being athletic (57% PwO and 49% HCPs), healthy (55% and 49%), or smart (41% and 32%) (Figure 2).

| Perceptions of current weight, WL attempts and outcomes
Although all PwO had obesity based on their self-reported weights and heights, 35% perceived themselves as having overweight and 10% perceived themselves as having normal weight.Nearly half (42%) perceived themselves as having obesity, and 12% perceived themselves as having extreme obesity.PwO started struggling with weight at a mean age of 30 years (median of 28 years), and it took them an average of 2 years (median of 1 year) from the time they started struggling with weight to initiate a weight discussion with their HCPs (Figure S3).Sentiments shared by PwO included feeling their life was controlled by their weight (48%) and that, despite best efforts or 'trying hard to resist', they would revert to previous eating habits (54%); however, 29% of PwO reported being happy with their weight (Figure 1).At a mean age of 38 years at the time of survey, the cohort of PwO, on average, made four serious attempts at WL in their adulthood with 74% of them making at least one serious effort (Figure S4A).Of those who lost weight, 52% reported weight regain after successfully maintaining WL for 6 months or more.In contrast, An obesity specialist is defined as a physician who reported seeing 50% or more patients specifically for obesity/weight management.
HCPs believed that only 49% of PwO under their care had made a serious WL effort (Figure S4B) and only 58% of those were successful.

| Interactions between PwO and HCPs
Less than half of PwO (43%) reported discussing weight with their HCPs in the past 5 years, and HCPs acknowledged discussing weight with slightly more than half (56%) of their PwO.When discussed, 47% of PwO reported initiating the dialogue, while more than half of HCPs (60%) reported initiating the conversation.The main reasons cited by PwO for not discussing weight with HCPs were the belief that WL was their sole responsibility (33%) and not having financial means to support their WL efforts (27%) (Figure 3, see Figure S5 for the full list of reasons for not having discussions about weight).HCPs perceived their patients having a lack of interest (41%) and not feeling motivated (37%) as the top reasons for which they would not initiate a WL discussion with patients (see Figures S3 and S5).
Overall, only 28% of PwO received a diagnosis of obesity from their HCP.Among those who had discussed weight with their HCP, 73% of PwO reported receiving a formal obesity diagnosis, and a similar proportion (72%) had a follow-up appointment scheduled with their HCP.Most HCPs (72%) recorded the obesity diagnosis in their patients' charts most or all the time but only informed 60% of their PwO of their diagnosis and scheduled a follow-up appointment in 49% of cases.The majority of PwO who discussed weight in the previous 5 years talked to an obesity specialist (57%), with slightly fewer engaging in discussion with a dietitian (50%) or primary care physician (46%) (Figure S6).

| Attitudes and perceptions of obesity management methods
PwO reported being more likely to rely on the internet, including social media (49%) and smartphone applications (39%) than an HCP (30%) for resources for obesity management (Figure S7).Both PwO (55%) and HCPs (77%) regarded employers as an important partner in PwO's efforts in obesity management (Figure S8).On average, PwO set themselves a WL goal of 23% of their total body weight (Figure S9).Most PwO (65%) preferred losing weight by themselves to taking medications, despite 50% of them acknowledging that there were good WL medications available (Figure 4).Nearly 40% of HCPs did not believe that there were good WL options for medications available, and both PwO and HCPs expressed strong concerns F I G U R E 1 PwO's and HCPs' attitudes toward obesity and weight management.Percentage of people with obesity (PwO) and healthcare providers (HCPs) who indicated their level of agreement was a 4 or a 5 on a 5-point scale where 1 meant 'Do not agree at all' and 5 meant 'Completely agree'.
about adverse effects and long-term safety associated with WL medications (Figure 4).In fact, nearly half of HCPs (45%) reported not being comfortable with prescribing WL medications due to a lack of knowledge.
The most common method recommended for obesity management by HCPs was lifestyle modification, specifically, improving eating habits (20%) and being physically active (20%); the least common methods included visiting a nutritionist/dietitian (14%), prescription weight loss medication (11%), and over-the-counter weight loss medications (10%).Fewer than half of PwO viewed anti-obesity medications (AOMs) (47%) and bariatric surgery (36%) as desirable options for WL.Nearly two-thirds of HCPs felt that their patients trusted them to prescribe a WL medication and that there are good options available today for WL medications, but only half thought that WL medications are more effective than other treatment options for WL (Figure 4).Both PwO (68%) and HCPs (71%) would rather use lifestyle changes than undergo or recommend bariatric surgery for WL, with most reporting bariatric surgery to be less effective than other obesity treatment modalities (52%), and considering it to be the last resort for WL (67%).While most HCPs (61%) believed cost is a major barrier for PwO to consider surgery, PwO were less likely to regard cost as a major impediment (53%).

| DISCUSSION
This study captured attitudes of PwO and HCPs regarding obesity and its management in nine South and Southeast Asian countries in the APAC region.Misalignment between PwO and HCPs in these areas was demonstrated through gaps in understanding of obesity approaches, discordance in treatment strategies, and management of obesity as a progressive, chronic disease.While some findings were consistent with those of ACTION studies conducted in other parts of the world, [6][7][8] there were important observations distinct to this region.This study found that APAC PwO were unique in being hesitant to discuss weight with their HCP and approach their HCP about WL strategies.Only 43% of PwO in our study had discussed their weight with an HCP in the past 5 years, compared to 54% of PwO in ACTION IO 6 and ACTION Canada, 8 and 71% in ACTION US 7 ; the HCPs we surveyed reported discussing weight with a smaller proportion of their patients (56%) than the HCPs in ACTION US (67%), 7 ACTION IO (68%), 6 and ACTION Canada (72%). 8Fewer HCPs in our study indicated the reasons for not initiating WL discussion with their patients were the perceived lack of interest (41% vs. 47% in ACTION US, 7 71% in ACTION IO 6 and 72% in ACTION Canada 8 ) and motivation among PwO (37% vs. 56% in ACTION US, 7 58% in ACTION Canada, 8 and 68% in ACTION IO 6,8 ).Additionally, the HCPs we surveyed reported informing only 60% of their patients of an obesity diagnosis, compared to 75% of patients as indicated by the HCPs in the ACTION IO study. 6ndamental to the discordance between attitudes and actual behaviours as defined in the survey is a poor appreciation among both PwO and, in some cases, HCPs, of the current state of knowledge of appropriate approaches to intervention, the biological underpinnings of obesity and the full recognition that obesity is a complex, multifactorial, chronic disease driven by its unique pathophysiology. 10While a significant proportion of PwO (68%) and HCPs (84%) regarded obesity as a chronic disease that has a serious impact on a person's health, this study demonstrates that misperceptions exist as to how PwO and HCPs view the various approaches to treatment for obesity.Hesitation of PwO and HCPs to initiate WL discussions combined with delays in seeking help contribute to suboptimal strategic approaches to weight management.
PwO reported being fairly hesitant to adopt medicinal and surgical treatments for obesity, and HCPs did not, overwhelmingly, report they prescribed or recommended these options for their patients with obesity.However, both groups acknowledged similar levels of concern about long-term safety and adverse effects of these modalities and expressed greater support for adopting lifestyle changes as the primary mechanism of treatment.PwO expressed a desire to lose a mean of 23% WL through lifestyle change, but more than a third reported they regained weight by no longer following their eating plan or no longer exercising.Similarly, PwO attributed their inability to maintain WL to a range of factors almost exclusively within their control, not related to genetics or biology, suggesting a need for greater education related to obesity, its pathophysiology and its drivers.
Basic public health education about healthy weight 11,12 and the unique impact of excess adiposity on obesity-related complications among South and Southeast Asians 11,13 are essential to encourage PwO to seek clinical care.Contributions of cultural and socioeconomic factors towards misperceptions of disease understanding are well established 14 and need to be considered when developing education and resources for the APAC region.For example, a greater proportion of PwO in our study were satisfied with their weight than was seen in the ACTION IO or ACTION US studies (39% vs. 6% and 20%, respectively). 6,15This could be due to cultural differences; a study in Taiwan and South Korea (not countries we studied but others in the APAC region) found that individuals were more likely to misperceive their weight and therefore have higher rates of body dissatisfaction. 13wever, the proportion of those who were, by BMI standards, considered underweight or normal weight (as determined by self-reported height and weight) was much higher than in other parts of the APAC region (57% for South Korea and 47% for Taiwan).In a similar vein, a more complete understanding, through better education, of the chronic disease status of obesity and the adaptive physiological changes at play that make WL and maintenance of WL extremely difficult, [16][17][18] should help dispel judgements of HCPs and others of PwO as unmotivated in their attempts to lose weight.In this respect, it is important to recognize that although slightly more than half of PwO reported that they were motivated to lose weight, PwO in this study felt that they were judged negatively in terms of their willpower, intelligence and ambition.The level of stigma PwO reported to feel, especially in a healthcare environment, suggests that weight stigma and blame among HCPs may fracture the therapeutic alliance, 12 resulting in PwO's reticence to engage in weight management in clinical settings.Further, clearer insights from PwO and HCPs of the 'detail' of the biology of obesity may reduce PwO self-stigma and stigmatizing attitudes among HCPs.Therefore, it will be important for HCPs to consider these factors when addressing WL and educating PwO about weight in the healthcare setting, as PwO will need to feel comfortable discussing weight with their HCP in order to advance their understanding of the disease.As this and other ACTION studies have shown, [6][7][8] opportunities exist for HCPs and PwO to have more collaborative discussions about WL, understanding that cultural differences and biases may be inherent in these conversations.

| Strengths and limitations
This study is a first of its kind focusing on the perceptions and attitudes on obesity and its management in Asia involving a very large cohort of PwO and HCPs, with the latter representing both primary care and specialists.The survey also included aspects on weight bias and stigma which were not included in the previous ACTION studies.
We recognize that some of the attitudes and perceptions of weight reported by both PwO and HCPs may have been inherently shaped by weight stigma and, in some cases, are a reflection of weight bias and stigma.We believe that this is a strength of the study, along with the anonymous nature of self-reporting, whereby people could be more honest in their responses.
As a self-reported cross-sectional survey of PwO and HCPs, with a substantial proportion of respondents from urban areas, responses may not be entirely representative of those in rural settings.However, we feel this study generally helps to give a voice to PwO in a region that has not previously been well studied.This survey relied upon participants' self-reported height and weight; BMI was not validated based on clinical data.We know from other research that there is a tendency for PwO to under-report their weight and overestimate their height 7,19 ; therefore, some of the results in this study may be slightly more conservative than others that directly measure heights/ weights and should be considered when interpreting the findings.In a study population of predominantly Asian descent susceptible to central obesity 20,21 the use of BMI alone may underestimate excess adi- The ACTION (Awareness, Care, and Treatment in Obesity maNagement) APAC study was conducted to: (1) identify perceptions and attitudes of PwO and HCPs toward obesity, (2) understand PwO's obesity management experiences; (3) assess interactions between PwO and HCPs; (4) understand perceptions and experiences with obesity management methods among PwO and HCPs in the APAC region.
(a) readiness to change/previous weight loss success; (b) awareness, perceptions, and attitudes toward obesity; (c) support structure; (d) interactions with HCPs with respect to obesity diagnosis and management, and (e) solutions to manage their weight.In the HCP questionnaire, participants were asked about: (a) their perception of their patients' readiness to change and their patients' previous weight loss success; (b) their personal awareness, perceptions, and attitudes toward obesity, (c) support structures they believe to be helpful to their patients; and (d) interactions with patients.For HCPs, additional information on demographics was asked, which included clinical speciality, years in practice, practice setting, frequency with which they diagnosed obesity in patients with obesity, comfort level of discussing weight, and the use of guidelines on obesity in their practice.Variables within the surveys were quantified using Likert scales, single and multiple item selection, and numeric entry (e.g., frequencies and percentages).A 5-point Likert scale (e.g., agreement, impact, frequency) was used to measure attitudes or opinions.A commonly used scale for agreement within the study measured from 1, 'strongly disagree', to 5, 'strongly agree'.Sixty-minute web-assisted pre-test interviews were conducted with six PwO and six HCP (three each of PCPs and specialists) in Indonesia, India, Pakistan, Thailand and Singapore to assess face validity prior to launch of the quantitative surveys.Participants took the survey online while speaking with an incountry moderator by telephone or in-person.Respondents received modest compensation for their participation.
ous statistical software packages, including SPSS (IBM, version 23.0), Stata (StataCorp LLC, version IC 14.2), and Excel (Microsoft, version 365).Descriptive statistical analyses (means, frequencies) of the aggregated data were performed using Q Research Software for Windows (A Division of Displayr, Inc., New South Wales, Australia).Tests of differences (chi square, t-tests) within respondent types were performed using Q Research Software tables.Categorical data are presented as counts and percentages.To mitigate selection bias, PwO data were weighted to representative demographic targets within each country for age, gender, household income, education and region within each country based on data from the 2011 International Standard Classification of Education (ISCED) and the US Census Bureau, International Data Base, and other public data.

T A B L E 2
Abbreviations: HCPs, healthcare providers; PwO, people with obesity.

F I G U R E 2
Perceptions of weight stigma as reported by PwO and HCPs.(A) Percentage of people with obesity (PwO) and healthcare providers (HCPs) indicating the level of difficulty of certain tasks or goals was a 1 or a 2 on a 5-point scale where 1 meant 'Much harder' and 5 meant 'Much easier.'Based upon the question, 'Compared to a person who does not have obesity, how easy or difficult do you think each of the following is for someone who has obesity?' to which respondents rated their answer on a 1 to 5 scale where 1 meant 'Much harder' and 5 meant 'Much easier'.(B) Percentage of people with obesity (PwO) and healthcare providers (HCPs) indicating the level of impact weight has on certain attributes was a 1 or a 2 on a 5-point scale where 1 meant 'Much harder' and 5 meant 'Much easier'.Based upon the question, 'Compared to a person who does not have obesity, how easy or difficult do you think each of the following is for someone who has obesity?' F I G U R E 3 Top reasons for not having weight discussions.Based upon the question to PwO, 'Which of the following are/would be the top five reasons for which you might not discuss managing your weight with your healthcare provider?' and to HCPs, 'What are the top 5 reasons for which you might not discuss obesity with a patient?' Respondents could select up to five answers in response to this question.
posity and not capture the full spectrum of PwO in this region of the world.Additionally, respondents participating in online surveys may be different from those who are not members of survey research panels, potentially reducing generalizability.In order to minimize bias, participants were unaware of the specific topic and purpose of the study until they met the eligibility criteria of the study.Selection bias was mitigated by weighting the PwO data to representative demographic F I G U R E 4 PwO and HCP attitudes toward prescription weight loss medication.Percentage of people with obesity (PwO) and healthcare providers (HCPs) who indicated their level of agreement was a 4 or a 5 on a 5-point scale where 1 meant 'Do not agree at all' and 5 meant 'Completely agree'.targets within each country for age, gender, household income, education and region within each country.5 | CONCLUSIONSThese findings highlight attitudes of PwO and HCPs that are different, if not unique, when compared with similar studies in other parts of the world.They also reflect areas where there is substantial misalignment between the two cohorts of PwO and HCPs.Questions related to stigma, whether they be internalized by PwO and derived from their social environment, or expressed inadvertently by HCPs through their attitudes regarding the level of motivation of their patients, reflect an underlying lack of in-depth understanding of the complexities of obesity.Greater engagement of PwO in their care, more effective public health messaging directed to the general community and more complete information and training available to HCPs may engender better utilization of interventions, improve the therapeutic alliance between PwO and HCPs, and reduce stigma, ultimately decreasing the negative impact of obesity.
Key demographics and characteristics of the study population.
a Obesity class definitions differ for Singapore, where Class I is BMI 27-31.9kg/m 2 , Class II is BMI 32-36.9kg/m 2 , Class III is BMI 37-41.9 and Class IV is BMI ≥ 42 kg/m 2 .b Percentages do not add to 100 because respondents could select more than one condition.c