Physician knowledge about and perceptions of obesity management.

ORCP-428; No. of Pages 11

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Obesity Research & Clinical Practice (2015) xxx, xxx—xxx

ORIGINAL ARTICLE

Physician knowledge about and perceptions of obesity management Terry Ann Glauser a,∗, Nancy Roepke a, Boris Stevenin b, Anne Marie Dubois b, Soo Mi Ahn b a b

CE Outcomes, LLC, 107 Frankfurt Circle, Birmingham, AL 35211, United States Novo Nordisk, 800 Scudders Mill Road, Plainsboro, NJ 08536, United States

Received 21 January 2015; accepted 24 February 2015

KEYWORDS Weight loss management; Physician practice patterns; Physician attitudes; Knowledge gaps; Obesity

∗

Summary Objective: Approximately 35% of US adults are obese. The purpose of this study was to assess the knowledge and practice patterns of primary care physicians (PCPs), endocrinologists (ENDOs), cardiologists (CARDs) and bariatricians (BARIs) regarding obesity. Methods: A case vignette survey was distributed to 1625 US-based PCPs, ENDOs, CARDs, and BARIs via email and fax in February 2013. Results were analysed with PASW Statistics 18. Results: Respondents included 100 PCPs, 100 ENDOs, 70 CARDs, and 30 BARIs. The majority agreed obesity is a disease as defined by the AMA, however, half of PCPs, ENDOs, and CARDs also agreed obesity results from a lack of self-control. Familiarity with select obesity guidelines was low. Nearly all respondents used body mass index for obesity screening. No consensus as to when to initiate weight-loss medication was observed. Many physicians expected a larger weight loss with pharmacotherapy than is realistic (∼30%) or were unsure (∼22%). A majority of PCPs, ENDOs and CARDs expected less excess weight loss with gastric bypass surgery than is realistic, BARIs had a more reasonable expectation. Conclusions: Overall, respondents demonstrated knowledge gaps for obesity guidelines and pathophysiology and generally lacked understanding of obesity medication efficacy, safety and MOA. © 2015 Asian Oceanian Association for the Study of Obesity. Published by Elsevier Ltd. All rights reserved.

Corresponding author. Tel.: +1 205 259 1500. E-mail address: [email protected] (T.A. Glauser).

http://dx.doi.org/10.1016/j.orcp.2015.02.011 1871-403X/© 2015 Asian Oceanian Association for the Study of Obesity. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: Glauser TA, et al. Physician knowledge about and perceptions of obesity management. Obes Res Clin Pract (2015), http://dx.doi.org/10.1016/j.orcp.2015.02.011


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T.A. Glauser et al.

Introduction Obesity is defined as having a body mass index (BMI) ≥30 kg/m2 and is recognised by the American Medical Association (AMA) as a disease involving the presence of an excessively high level of body fat in relation to lean tissue putting people at health risk [1,2]. The latest data (2011—2012) from the National Health and Nutrition Examination Survey, National Center for Health Statistics find that 35% of adults in the United States (US) are obese [3]. Obesity is the second leading cause of preventable death in the US and is a leading cause of morbidity, disability, healthcare utilisation, and healthcare costs [4]. Annual medical costs for individuals who are obese are 42% higher than for people with normal weight [5]. The medical costs of obesity in the US may be as high as $186 billion, with 17% of national health expenditures used to manage obesity-related conditions [6]. Patients who are obese have an increased risk of comorbidities such as type 2 diabetes, cardiovascular disease, hypertension, dyslipidaemia, osteoarthritis, certain types of cancers, benign prostatic hyperplasia, reduced fertility, asthma, obstructive sleep apnoea, and other respiratory problems [7,8]. Obesity in adults is also associated with psychosocial complications such as emotional distress, prejudice, discrimination (in employment, healthcare, education, interpersonal relationships, the media), reduced quality of life, and social stigmatisation [9]. Despite the association of obesity with psychosocial complications and other comorbid conditions and the availability of weight management guidelines, physicians’ rates of screening, diagnosing and management of obesity are low. In a 2007 study of 140 primary care physicians (PCPs) by Bardia et al., only 19.9% of obese patients had a recorded diagnosis of obesity and 22.6% had a documented obesity management plan [10]. Boardley et al. ascertained that the 47 family medicine physicians they studied had calculated a BMI for 63.5% of patients with a BMI >25 kg/m2 and half or less of these patients had received education on weight loss through diet and exercise [11]. Ma et al. performed an analysis of the 2005 and 2006 National Ambulatory Medical Care Survey (NAMCS). Half of office visits to physicians with specialties of primary care or cardiovascular disease lacked enough data to screen for BMI, thus 70% of patients who are obese were not diagnosed, and 63% received no counselling about diet, exercise, or weight reduction [12]. Bleich et al. analysed data from the 2005 NAMCS and determined that 28.9% of obese adults in the practices studied (63% PCP, 10% cardiology and

internal medicine, 27% other) received an obesity diagnosis, and one-quarter or less were counselled about weight reduction, diet, and exercise [13]. Smith et al. surveyed 1211 PCPs and found that less than half regularly recorded BMI or always provided specific guidance on diet, exercise, or weight control [14]. However more than 70% of respondents had prescribed pharmacologic treatment for overweight patients and 86% had referred patients for evaluation for bariatric surgery [14]. With the exception of the Bleich study, which included cardiologists (CARDs), there have been no recent studies of the practice patterns of CARDs and endocrinologists (ENDOs) with respect to the diagnosis and management of obesity. PCPs, ENDOs, and CARDs manage patients with a variety of health conditions, which may lead to obesity being a lower priority. However, as obesity is a significant risk factor for many other conditions, the early diagnosis and management of obesity are essential. Bariatric medicine is a growing specialty performed by physicians with a specific interest in obesity. The American Board of Bariatric Medicine was established in 1970 so that bariatricians (BARIs) could obtain credentials for their practices. Currently, BARIs, who come from a diverse background including PCPs, CARDs, and ENDOs, comprise physicians who are credentialed by the American Board of Obesity Medicine (ABOM). There are 850 BARIs certified by the ABOM, far fewer than are needed to manage all patients who are obese. Patients who are obese may be diagnosed and/or managed by their PCP or by specialists who manage their comorbid conditions such as type 2 diabetes or cardiovascular disease, such as ENDOs or CARDs, or by BARIs. The field of obesity management is rapidly changing and PCPs, ENDOs, CARDs, and BARIs need to keep abreast of these changes. This study explored the primary educational needs, attitudes, practice patterns and barriers facing USbased PCPs, ENDOs, CARDs and BARIs, with respect to obesity screening and management to provide information on the educational gaps of these physicians.

Methods Four similar survey instruments for PCPs, ENDOs, CARDs, and BARIs were developed to examine the attitudes, knowledge and decisions about, and barriers to the management of obesity for PCPs, ENDOs, and CARDs, who may not practice bariatric medicine, in addition to BARIs. The surveys presented several hypothetical patients in progressive case vignettes, and included questions addressing



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Physician perceptions of obesity management perceptions about and attitudes towards obesity, use of obesity guidelines, and the use of pharmacologic and surgical management strategies. Some survey items used a 10-point Likert scale (1 = least, 10 = most) to assess perceptions and attitudes. Prior to distribution, surveys were pilot tested with practicing healthcare providers in the intended target audiences to ensure clarity and validity of the cases and questions. Based on information available in the 2011 Annual American Medical Association Physician Characteristics and Distribution US Report, survey invitations were distributed to a nationally representative random sample of 1625 US-based practicing PCPs (Family Practice, Internal Medicine), ENDOs, CARDs, and BARIs by email and fax during February 2013. A variety of self-reported demographic and practice information about the participants was collected and individual participants were directed to the survey tailored for their specialty. Inclusion criteria for survey participants required the respondent to be a practicing clinician in their specialty and see at least 1 patient per week who is obese. Study participants received a professionally appropriate honorarium for completing the survey. To adequately power the survey, 300 responses were collected with a pre-planned distribution of respondents: 100 PCPs, 100 ENDOs, 70 CARDs, and 30 BARIs. When adequate numbers of surveys were completed by each specialty group, data collection for that group stopped. Responses were aggregated by specialty for data analysis. Data were analysed with PASW Statistics 18 (SPSS, Chicago, IL). Descriptive statistics were used to summarise survey responses.

Results Study population The demographic characteristics of the physicians responding to the survey are listed in Table 1. As a whole, respondents had a depth of experience, ranging from a mean of 24 years in practice for ENDOs to a mean of 29 years in practice for BARIs. Mean number of patients seen per week ranged from 116 for PCPs to 88 for BARIs. For PCPs and CARDs, an average one-third of their patients were obese compared with 46% for ENDOs and 75% for BARIs.

Attitudes and knowledge regarding obesity Physicians were asked a series of questions regarding their perceptions and knowledge of

3 factors which may contribute to obesity (Table 2). A large majority of all groups somewhat agreed or agreed with the statement ‘‘Obesity is a disease as defined by the AMA’’. Further, 47% of PCPs, 51% of ENDOs, and 54% of CARDs somewhat agreed or agreed that obesity is the result of a lack of self-control; however, only 20% of BARIs somewhat agreed with this statement, and none completely agreed. Most respondents somewhat agreed or agreed that patients are primarily responsible for their own weight management. When asked to rate their agreement with the statement ‘‘I can help patients who are obese achieve a healthy weight’’, 82% of PCPs, 64% of ENDOs, and 73% of CARDs somewhat agreed or agreed; 90% of BARIs somewhat agreed or agreed with the statement ‘‘I am successful in helping my patients who are obese lose weight’’. Upon examining the significance of barriers in communicating about weight with their patients, the majority of respondents rated each barrier such as fear of offending the patient or lack of training as not (11—47%) or only somewhat significant (41—57%) (Table 3). Respondents were asked to identify the hormone which increases food intake (Table 2). When presented with the choice of glucagon-like-peptide 1, ghrelin, cholecystokinin, and amylin, at least 70% of ENDOs and BARIs correctly identified the hormone ghrelin, whereas fewer than 30% of PCPs and CARDs did so.

Familiarity with guidelines Respondents were asked to rate their familiarity with four guidelines from major institutions and associations which provide recommendations for the management of obesity: The U.S. Preventative Services Task Force (USPSTF) guidelines [15], those from the National Heart, Lung, and Blood Institute (NHLBI) [16], the American Academy of Clinical Endocrinology (AACE)/The Obesity Society (TOS)/American Society for Metabolic & Bariatric Surgery (ASMBS) [17], and the Institute for Clinical Systems Improvement (ICSI) guidelines [18] (Table 4). The guidelines most familiar to the physicians (indicated by a response of ‘‘very familiar’’) were the AACE/TOS/ASMBS guidelines on the perioperative support of the bariatric surgery patient (PCPs 14%, ENDOs 39%, CARDs 6%, and BARIs 50%). The NHLBI and USPSTF had similar levels of familiarity. The ICSI guidelines had the fewest physicians who are ‘‘very familiar’’ (PCPs 12%, ENDOs 11%, CARDs 4%, and BARIs 10%). BARIs had the highest percentage of respondents who were ‘‘very familiar’’ with guidelines but overall the familiarity



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T.A. Glauser et al. Table 1

Demographics of respondents.

Characteristic Years since medical school graduation (mean) Specialty Family practice (%) Internal medicine (%) Endocrinology (%) Cardiology (%) Bariatrics (%) Bariatric surgery (%) Patients seen per week (mean) % patients seen who are obese (mean) % patients seen who are overweight (mean)

PCPs (n = 100)

Endocrinologists (n = 100)

Cardiologists (n = 70)

Bariatricians (n = 30)

26

24

27

29

56% 44% — — — — 116

— — 100% — — — 109

— — — 100% — — 106

— — — — 70% 30% 88

33%

46%

33%

75%

34%

36%

37%

36%

(—) Respondents were not presented with question.

with guidelines were relatively low, notably among CARDs.

respondents used other methods of diagnosis. Waist circumference was the third most used method.

Screening for obesity

Attitudes and practices regarding pharmacologic treatment for weight loss

Respondents were asked about obesity screening methods they routinely use (Table 5). A majority of respondents used body mass index (BMI) as recommended by guidelines, followed by weight. Fewer

Indications for weight loss medication Physicians were presented with a case vignette describing an individual who is obese with several comorbidities and risk factors, and were then asked

Table 2

Attitudes and knowledge about obesity. Bariatricians (n = 30)

Obesity is a disease as defined by the AMA (% selecting ‘‘agree’’, ‘‘somewhat agree’’) Obesity is the result of a lack of self-control (% selecting ‘‘agree’’, ‘‘somewhat agree’’) I can help overweight and obese patients achieve a healthy weight (% selecting ‘‘agree’’, ‘‘somewhat agree’’) I am successful in helping my overweight and obese patients lose weight Patients are primarily responsible for their own weight management Hormone that increases food intake Ghrelina Glucagon-like-peptide 1 Cholecystokinin Amylin Unsure



PCPs (n = 100)

97.0%

83.0%

83.0%

80.0%

20.0%

54.0%

51.0%

47.0%

73.0%

64.0%

82.0%

—

90%

—

—

—

93%

74%

75%

81%

70.0% 6.7% 0.0% 0.0% 23.3%

28.6% 12.9% 2.9% 4.3% 51.4%

78.0% 3.0% 7.0% 1.0% 11.0%

20.0% 30.0% 10.0% 2.0% 38.0%

(—) Respondents were not presented with question. a Correct answer.



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Physician perceptions of obesity management Table 3

5

Barriers in communicating with patients who are obese about their weight. Bariatricians (n = 30)



Fear of offending the patient by raising the issue Not significant — 47% 35% Somewhat significant — 41% 57% Very significant — 11% 8% Concern that patient is not interested in discussing the issue Not significant — 41% 24% Somewhat significant — 47% 56% Very significant — 11% 20% Lack of training on how to discuss obesity Not significant 47% 31% 41% Somewhat significant 40% 54% 48% Very significant 13% 14% 11% Lack of resources to which I can refer overweight and obese patients Not significant — 24% 24% Somewhat significant — 51% 43% Very significant — 24% 33% Low likelihood of succeeding in helping my patients achieve or maintain a healthy weight Not significant — 11% 15% Somewhat significant — 56% 44% Very significant — 33% 41%

PCPs (n = 100) 35% 52% 13% 27% 55% 18% 46% 43% 11% 23% 48% 29% 17% 51% 32%


to indicate which characteristics they would consider to be indications for weight loss medication (Table 6). Responses varied widely between the groups of physicians but the most selected indication across all groups was BMI ≥30 kg/m2 . The patient’s Mexican American ancestry was not a significant factor for initiating weight loss medication in any group.

Table 4

Weight loss expected after medical treatment Physicians were asked to select the percentage of expected weight loss for a 31-year-old African American woman with a BMI of 47 kg/m2 after one year of treatment with a serotonin 2c receptor agonist (Table 6). The most frequently selected expectation by all groups was a 5% weight loss. In general, a weight loss of ≥5% is considered by the

Familiarity with guidelines. Bariatricians (n = 30)


Familiarity with clinical guidelines for obesity (10-point familiarity scale, means) USPSTF screening and 3.5 5.8 management of obesity in adults 5.2 NHLBI Guidelines on 3.5 Identification, Evaluation, and Treatment of Overweight and Obesity in Adults 6.5 2.8 AACE/TOS/ASMBSM guidelines for clinical practice for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient ICSI — prevention and 2.5 3.7 management of obesity guideline


PCPs (n = 100)

5.0

5.6

5.0

4.6

6.2

4.0

3.2

3.7

USPSTF, Unites States Preventive Services Task Force; NHLBI, National Heart, Lung, and Blood Institute; AACE, American Academy of Clinical Endocrinology; TOS, The Obesity Society; ASMBS American Society for Metabolic and Bariatric Surgery; ICSI, Institute for Clinical Systems Improvement.



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Screening for obesity. Bariatricians (n = 30)


Measures used to screen and identify a patient as obese Body mass index 96.7% 95.5% Weight 90.0% 80.3% Waist circumference 46.7% 31.8% Neck circumference 20.0% — Weight/height table 26.7% 19.7% Waist/hip ratio 23.3% —


PCPs (n = 100)

99.0% 70.1% 41.2% — 16.5% —

96.5% 79.1% 38.4% — 30.2% —


FDA to be clinically meaningful and clinical trials have demonstrated that significantly more patients treated with a serotonin 2c receptor agonist than placebo lost ≥5% or ≥10% of their initial weight [19—22]. A considerable percentage of physicians expected a larger amount of weight loss of 15% (PCPs 32%, ENDOs 21%, and CARDs 36%). Approximately one-fourth of all the respondents were ‘‘unsure’’ (PCPs 25%, CARDs 24%, BARIs 30%), with the exception of ENDOs (7% ‘‘unsure’’). Perceptions of weight loss medication safety and efficacy Substantial percentages of physicians in all groups somewhat or completely disagreed with the statements ‘‘currently available medications for obesity are safe’’ (PCPs 42%, ENDOs 36%, CARDs 54%, and BARIs 20%) and ‘‘currently available medications for obesity are effective’’ (PCPs 39%, ENDOs 40%, CARDs 57%, and BARIs 37%), as shown in Table 6. Mechanism of action of weight loss medications The respondents were presented with four statements linking weight loss medications to a mechanism of action (Table 6). The percentage of respondents who selected the correct corresponding response for serotonin 2c agonists as exhibiting 5HT2C receptor action varied among groups (twothirds of ENDOs and BARIs but only a third of PCPs and CARDs). A notable percentage from each group was ‘‘unsure’’.

Practices and perceptions regarding surgical treatment for weight loss Participants were asked the amount of weight they expect a patient who has approximately 150 lbs of excess body weight to lose 1 year after Roux-en-Y gastric bypass (Table 7). In accordance with guideline expectations of a 60—70% excess body weight loss (EBWL), BARIs more frequently (40%) expected a loss of 60% of excess weight [23]. However, this

expectation was only shared by 14% of PCPs, 38% of ENDOs, and 20% of CARDs. A 50% EBWL was anticipated most frequently by PCPs (60%), ENDOs (44%), and CARDs (51%), whereas 30% of BARIs had this expectation. A loss of 80% of excess weight was considered by 27% of BARIs but infrequently anticipated by PCPs (11%), ENDOs (10%), and CARDs 10%. Considerable percentages of PCPs (14%) and CARDs (17%) were unsure. Bariatricians were asked to select patient scenarios in which they would recommend bariatric surgery. The most frequently selected case was a 50-year-old woman with a BMI of 40 kg/m2 and no comorbidities (80% of BARIs), followed by a 35-yearold woman with a BMI of 35 kg/m2 and a history of nonalcoholic fatty liver disease (60% of BARIs), as shown in Table 7.

Discussion Physicians regularly encounter patients who are obese, yet studies have demonstrated that physicians often do not screen for obesity or manage it. A number of recent studies have shown that physicians feel unprepared to care for patients who are obese [24—27]. This study elucidated the attitudes and perceptions about, knowledge of, and practice patterns regarding obesity in four groups of physicians who routinely care for patients with obesity and comorbid conditions, with the goal of identifying areas where education can improve patient care. In this study, almost all respondents agreed that obesity is a disease, in accord with a 2003 study of primary care physicians [28], in which 92% agreed that obesity is a chronic disease and a 2006 study where 86% agreed [29]. However, about half of PCPs, ENDOs, and CARDs also agreed that obesity is the result of a lack of self-control, indicating an ambivalence about obesity as a disease state among these three groups of physicians. Although the communication barriers were mostly rated as



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Physician perceptions of obesity management

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Table 6 Knowledge and perceptions about weight loss pharmacotherapy. Case: A 51-year-old Mexican American construction worker recently started a new job and comes to see you for the first time for an employee physical. He reports previous hypertension treatment but no significant other medical history. He smokes 1 pack of cigarettes per day. He takes no medications, drinks alcohol only rarely, uses no illicit substances, and reports no allergies. His height is 5 7 tall, and weight is 183 lbs (BMI 28.7 kg/m2 ). His blood pressure is 150/90 mmHg. The remainder of his physical examination is normal. You make some initial recommendations for lifestyle changes to the patient for weight loss and blood pressure control and ask him to return in 8 weeks. However, he misses his appointment and returns a year later. He lost his job and consequently his health insurance shortly after you saw him, and has been struggling to find work. On physical examination, his weight is now 217 lbs (BMI 34.0 kg/m2 ). His blood pressure is 160/100 mmHg. Bariatricians (n = 30)


Indications for weight loss medication for this patienta Hypertension 46.7% 48.6% BMI ≥30 kg/m2 70.0% 55.7% Failure to lose weight after 42.9% 63.3% recommendations for lifestyle changes Mexican-American ancestry 0.0% 8.6% Unsure 6.7% 35.7% Weight loss expected with a serotonin 2c receptor agonist 2% 7.0% 0% 43.0% 40.0% 5%b 10% 20.0% — 15% 0.0% 35.7% 25% — 0.0% Unsure 30.0% 24.3% Disagreement with safety/efficacy of obesity medications (% selecting ‘‘somewhat disagree’’ and ‘‘disagree’’) Currently available medications for obesity 54.0% 20.0% are safe Currently available medications for obesity 57.0% 37.0% are effective Identification of correct mechanism of action of weight loss medication Serotonin 2c receptor agonist acts primarily 60.0% 37.1% on the 5HT2C receptor to promote weight lossb 1.4% 0.0% Sympathomimetic amine promotes weight loss by restricting absorption of fat from the small intestine 2.9% 0.0% Aminoketone antidepressant promotes weight loss primarily through its action on the cannabinoid CB1 receptor 0.0% 0.0% Lipase inhibitor promotes weight loss by acting centrally on the serotonergic system Unsure 40.0% 58.6%


PCPs (n = 100)

74.0% 75.0% 65.0%

66.0% 65.0% 45.0%

11.0% 10.0%

22.0% 18.0%

1.0% 70.0% — 21.0% 1.0% 7.0%

1.0% 38.0% — 32.0% 4.0% 25.0%

36.0%

42.0%

40.0%

39.0%

58.0%

33.0%

11.0%

7.0%

3.0%

6.0%

2.0%

5.0%

26.0%

49.0%

(—) Respondents were not presented with question. a Respondents were allowed to select more than one option. b Evidence-based response.

not or only somewhat significant in this survey, the literature still demonstrates the presence of common barriers [30] in discussing weight with patients, which may include its perceived ineffectiveness [31]. Respondents were also asked about the physiology of obesity. Recent research has led to an increased understanding of the hormonal control of

food intake [32]. In particular, it has been shown that ghrelin, produced in gastric oxyntic glands, stimulates food intake and decreases fat utilisation in response to weight loss, fasting, and hypoglycaemia [32]. Less than one-third of PCPs and CARDs correctly selected ghrelin as the hormone having a role in increased appetite; between 11% (ENDOs)



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Knowledge about bariatric surgery.

Expected excess weight loss for patient who is roughly 150 lbs overweight 1 year after laparoscopic Roux-en-Y gastric bypass 50% 60%a 80% 90% Unsure Patients to recommend for bariatric surgery 50-Year-old woman with a BMI of 40 kg/m2 and no co-morbidities 35-Year-old woman with a BMI of 35 kg/m2 and a history of non-alcoholic fatty liver disease 53-Year-old woman with a history of heroin abuse and a BMI of 44 kg/m2 who has not used drugs in roughly 1 year 22-Year-old man with a BMI of 36 kg/m2 and a history of mild-to-moderate obstructive sleep apnoea 75-Year-old man with a BMI of 45 kg/m2 and a history of stable coronary disease, type 2 diabetes, dyslipidaemia, and hypertension

Bariatricians (n = 30)



PCPs (n = 100)

30.0% 40.0% 26.7% 0.0% 3.3%

51.4% 20.0% 10.0% 1.4% 17.1%

44.0% 38.0% 10.0% 2.0% 6.0%

60.0% 14.0% 11.0% 1.0% 14.0%

80.0%

—

—

—

60.0%

—

—

—

33.3%

—

—

—

30.0%

—

—

—

16.7%

—

—

—

(—) Respondents were not presented with question. a Evidence-based response.

and 51% (CARDs) of respondents were unsure which hormone increases food intake. The gaps in attitude about obesity for PCPs, ENDOs, and CARDs, and in understanding of the pathophysiology of obesity by all groups reveals a need for more education about the complex pathophysiology of obesity. Indeed, with ongoing research about the pathophysiologic basis of obesity, this will be an area where continued education will be needed. In addition, simple and effective tools to assist with overcoming barriers to initiate and continue open dialogue with their patients about weight are needed. To assist physicians in the management of obesity, evidence-based guidelines have been published by a number of medical organisations and by U.S. government entities. However, familiarity with these guidelines was low among physicians who responded to this survey. Lack of familiarity with guidelines may be related to physicians’ not making obesity management a high priority and therefore not feeling they need to be familiar with guidelines. However, it is also possible that survey respondents are more familiar with other obesity management guidelines aside from the 4 included in the survey (over 30 were found in our 2013 literature review) or rely on their own professional experience to guide their decision making.

Nearly all respondents use BMI to screen for obesity; patient weight was also used by 70% or more of respondents, and waist circumference is used by less than half of respondents. Several studies have shown that BMI and waist circumference may be inaccurate measures of obesity, based on patient age, gender, and body habitus [33—35]. Clinicians need further education on the potential for misclassification of patients and the need to consider each patient’s individual physiology when deciding whether a patient is obese. Respondents were asked to identify patient features influencing their decision to recommend pharmacotherapy for weight loss for a patient in a case vignette. Multiple patient characteristics were selected as indications for initiating pharmacotherapy for obesity. A BMI ≥30 kg/m2 is an accepted parameter for starting pharmacotherapy in an otherwise healthy individual [16,18,36]. However, approximately one-third of the physicians in this study did not select it as a parameter that would lead them to prescribe weight loss pharmacotherapy. One-quarter or more of respondents did not think that obesity with comorbid hypertension was an indication to begin pharmacotherapy, although patients with a BMI ≥27 kg/m2 who have concomitant obesity-related disease are also



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Physician perceptions of obesity management candidates for weight loss pharmacotherapy [16,18,36]. It is possible that respondents did not consider the level of comorbid hypertension presented in the case (160/100 mmHg) as severe enough to use as a criterion for starting weight loss pharmacotherapy. The patient’s failure to lose weight after recommendations for lifestyle changes may not have been selected as a criterion by all as this patient was not compliant with those recommendations and physicians may have felt that the patient needed to renew his efforts at lifestyle changes before starting pharmacotherapy. Physicians in all groups may benefit from more information about the indications for starting weight loss pharmacotherapy. In this study, physicians in all groups did not perceive currently available weight loss medications to be safe or effective. This pessimism about medication safety and efficacy is congruent with findings from another recent publication [25]. However, a substantial percentage of physicians in all groups expected more weight loss when using a serotonin 2c receptor agonist than was demonstrated in a clinical trial [20—22] and with the exception of ENDOs, about one-quarter of respondents were unsure of how much weight loss to expect. The fact that respondents were expecting greater weight loss with the use of pharmacotherapy than typically observed or were unsure may be a contributor to physician perception of current agents as ineffective. In addition, most PCPs and CARDs, and a sizeable minority of ENDOs and BARIs, were unable to correctly identify a weight loss pharmacotherapy with its mechanism of action, highlighting the gap in knowledge about these agents among all groups. Among PCPs, ENDOs, and CARDs, expectation of excess weight loss after Roux-en-Y gastric bypass was lower than that demonstrated in clinical trials [37], while BARIs had a more realistic expectation of postoperative results. This low expectation for gastric bypass may cause physicians to not recommend it to patients. If physicians perceive that they have less success with pharmacotherapy than they expect and more success with bariatric surgery, they may tend to recommend surgery to patients that could be managed with pharmacotherapy. Physicians need education on the efficacy of various options for managing obesity.

Limitations Study limitations include the use of a case-based survey as a surrogate measure of clinicians’ skills,

9 knowledge, and attitudes that were self-reported. While results from recent research demonstrate that case vignettes (compared to chart review and standardised patients) are a valid and comprehensive method to measure processes of care in actual clinical practice [38—40], survey participants may have selected the response they perceived as the answer survey developers expected or was more appropriate instead of how or what they actually practice or believe. Two clinical scenarios were used within the survey instruments, which do not cover the full spectrum of patient demographics, comorbidities, medical and personal histories that clinicians may encounter. Respondents received a small honorarium to complete the study, which could influence participation rates and responses. Despite this potential source of bias, demographic characteristics of our sample were not different, in comparison to the 2010 American Medical Association data, from that of the population of physicians. Finally, the cross-sectional design of the study does not allow for causal inferences to be drawn.

Conclusions It is crucial for PCPs, ENDOs, CARDs, and BARIs to be able to appropriately screen, counsel and manage patients who are obese. We have uncovered several important areas of unmet educational needs for these physician groups with respect to obesity. Physicians require more knowledge of current evidence-based guidelines for screening and management of obesity as a basis to individualise each treatment plan. They also need greater education with respect to an understanding of the hormonal basis of appetite regulation and the overall pathophysiology of obesity. To correctly prescribe weight-loss medications, physicians need to know when to initiate weight loss pharmacotherapy, its mechanism of action, the efficacy, and the safety of each agent. Additionally, physicians should understand the expected weight loss from weight loss medications and bariatric surgery.

Acknowledgements The study was a joint collaboration, with all authors playing a key role in the definition of the study focus. Dr. Terry Glauser and Nancy Roepke implemented the study with additional assistance from CE Outcomes staff, including Ben Whitfield who assisted with data collection and analysis. All authors were involved in writing the article and had



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T.A. Glauser et al.

final approval of the submitted and published versions. This study was supported by Novo Nordisk Inc.

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