Are General Practitioners Ready and Willing to Tackle Obesity Management?

Obesity Research & Clinical Practice (2008) 2, 189—194

ORIGINAL ARTICLE Are general practitioners ready and willing to tackle obesity management?

Laurien M. Buffart a, Margaret Allman-Farinelli b, Lesley A. King b, Hidde P. van der Ploeg c,∗, Ben J. Smith d, John Kurko e, Adrian E. Bauman c a Department of Rehabilitation Medicine, Erasmus MC, University Medical Center, Rotterdam, The Netherlands b Centre for Overweight and Obesity, University of Sydney, School of Public Health, Sydney, Australia c Centre for Physical Activity and Health, University of Sydney, School of Public Health, Sydney, Australia d Department of Health Science, Monash University, Frankston, Australia e National Heart Foundation of Australia, Sydney, Australia

Received 30 April 2008; accepted 30 April 2008

KEYWORDS Summary General practitioners; Objective: To investigate general practitioners’ (GPs’) knowledge, role perception, Obesity; confidence and practices of managing adult and childhood overweight and obe- Overweight; sity, and to explore the association with GPs’ attendance at Continuing Professional Management; Development (CPD) on overweight and obesity. Counselling Methods: In 2007, all GPs in seven Divisions of general practice in New South Wales were sent a questionnaire on GPs perceptions and practices of weight counselling. Results: 646 GPs participated (40% response rate). About half of the GPs (47%) believed that only a small percentage of adults could reduce weight and maintain that loss, whereas 33% had a similar belief in relation to children. Most GPs believed that it was their role to manage weight and felt confident to do so with adults, but fewer GPs felt confident in managing children. Nevertheless, just over one-third of GPs reported they counselled more than 10 adult patients, and a similar proportion counselled more than 3 children per week. GPs who felt more confident were more likely to counsel adults (OR = 2.69, p = 0.001) and children (OR = 3.31, p < 0.001). Those who received CPD were more likely to feel confident in managing adults (OR = 1.56, p = 0.031) and children (OR = 2.19, p < 0.001).

∗ Corresponding author at: Centre for Physical Activity and Health, University of Sydney, Level 2, Medical Foundation Building (K25), Camperdown, NSW 2006, Australia. Tel.: +61 2 9036 3288; fax: +61 2 9036 3184. E-mail address: [email protected] (H.P. van der Ploeg).

Conclusions: Although the majority of GPs believe that weight management is their role, only a small proportion regularly provided counselling. This may partly be the result of GPs confidence in managing patients, especially children. CPD on overweight and obesity may benefit GP confidence, but additional training is needed to improve GP’s counselling behaviour, particularly for children. © 2008 Asian Oceanian Association for the Study of Obesity. Published by Elsevier Ltd. All rights reserved.

Introduction discuss adult and childhood overweight and obesity with patients, and the relationship between Recent surveys showed that around one in two Aus- these factors and the extent to which this issue tralian adults and one in four Australian children are was actually addressed in patient consultations. overweight or obese [1,2]. General practitioners The contribution of Continuing Professional Devel- (GPs’), patients and the wider community believe opment (CPD) on overweight and obesity to GP that GPs can play a key role in managing obesity confidence and frequency of discussing overweight and other risk factors for chronic disease [3—5].To and obesity was also examined. support this role, several countries, including Aus- tralia, have developed clinical practice guidelines for the assessment and management of overweight Methods and obesity [6—8]. In 2000, a study on GPs attitudes and practices Data collection on overweight and obesity management in Australia reported that many GPs felt they had an impor- A questionnaire on GP perceptions and practices tant role in obesity management and prevention, on adult and childhood overweight and obesity and that 70% and 58% of GPs found themselves was included in a survey of GP perceptions and well prepared to manage overweight and obesity, practices in physical activity counselling. In March respectively [9]. 2007, the questionnaire was mailed to all GPs that Nevertheless, studies consistently show that GPs were registered within one of five urban (Canter- do not routinely assess patients’ weight status bury, Macarthur, Hawkesbury-Hills, Central Coast or provide advice on related lifestyle risk factors and Hunter Urban) and two rural (South East NSW [10—12], and that there are significant barriers, and Central West) Divisions of the 37 Divisions of such as absence of reimbursement arrangements, General Practice in New South Wales, Australia. The referral options, consultation time and perceived selected Divisions were thought to be typical of New efficacy [9,13,14]. There have been considerable South Wales as they cover urban and rural Divisions. efforts to promote GPs’ role in providing assess- In order to improve the response rate, one reminder ment and advice in relation to smoking, nutrition, was mailed to GPs, and small prizes were awarded alcohol and physical activity risk factors amongst to six randomly selected GPs who had returned adults, through new tools, training programs and the survey. In total, 646 GPs (40%) responded to Medicare funded health checks [15,16]. Despite the the questionnaire. The study was approved by the high political and media profile of obesity in recent Research Committee of the Royal Australian College years, far fewer programs or resources to support of General Practitioners New South Wales Faculty. GPs in addressing weight status in adults or children have been developed or funded [9,17]. Measurements Because of the rising prevalence of overweight and obesity in Australia, and associated chronic dis- In order to measure knowledge, role perception, eases, it is important to monitor the capacities and and confidence, GPs were asked to rate their agree- practices of GPs in addressing this. There are lim- ment on a five-point Likert scale with statements ited data on whether GPs are giving overweight that included: ‘only a small proportion of patients and obesity equal or greater attention among can reduce BMI and maintain that loss’, ‘the best their adult or paediatric patients, although the role for a GP is to refer overweight and obese latter have been recognized as presenting partic- patients to other professionals rather than attempt- ular challenges [3]. The current study investigated ing to treat them’, and ‘I’m professionally well GPs’ knowledge, role perception and confidence to prepared to manage patients who are overweight Obesity management in general practice 191

Table 1 Characteristics of the general practitioners been in practice for 21 years, saw around 118 included in the survey patients per week and 78% were from an urban area. Characteristic (n = 646) Gender: male, n (%) 366 (58) Years in practice, mean (S.D.) 21 (12) Number of patients per week, mean 118 (70) Knowledge, conﬁdence and role perception (S.D.) Table 2 shows that almost half of the GPs thought Area, n (%) only a small percentage of adults would be able Rural 141 (22) to lose weight and maintain the loss for a year. Urban 505 (78) Nearly all GPs (92%) disagreed that their best role in managing overweight or obese adults was S.D.: standard deviation. to refer them to other professionals and the majority (77%) believed they were professionally well prepared to manage adult overweight or obese’. GP’s were also asked how many patients or obesity. There was a lower proportion (33%) they had discussed overweight or obesity with in of GPs who believed only a small proportion of the previous week. All of these items were asked children can reduce BMI and maintain this loss separately in relation to adult and childhood over- for more than a year, and again the majority weight and obesity. In addition, GPs were asked (79%) disagreed that their best role was to refer whether they had attended CPD on overweight and overweight or obese children to other profession- obesity. Data collected about respondents included als. Fewer GPs felt they were well prepared to gender, average number of patients seen per week manage childhood overweight and obesity (41%), and years in practice. compared with managing this problem among adults. Statistical analyses

Questions using a five-point Likert scale were Discussing overweight and obesity with dichotomized by combining the two ‘agree’ options patients and combining the ‘neutral’ and the two ‘disagree’ responses. Frequency of discussing adult over- Thirty-seven percent of GPs discussed adult overweight or obesity with patients was dichotomized weight or obesity with 10 or more patients per week at ten or more patients per week and frequency and 36% discussed childhood overweight or obesity of discussing childhood overweight or obesity with 3 or more patients per week. was dichotomized at three or more patients per After adjusting for GP’s gender and total number week. of patients seen per week, GPs who felt confi- Logistic regression analyses were performed to dent in their professional preparation for managing study whether the GPs’ frequency of discussing overweight and obesity were 2.69 (95% confidence overweight and obesity with patients was related interval (CI) = 1.49, 4.87; p < 0.001) times more to their knowledge, confidence, role perception likely to manage adults and 3.31 (95% CI = 2.10, and whether they had attended CPD. In addition, 5.22; p < 0.001) times more likely to manage chil- the association between attendance at CPD and dren (Table 2). GP knowledge and perceived role GP confidence was examined. P-values < 0.05 were were not associated with the numbers of patients considered statistically significant. Bivariate analy- counselled. ses revealed that GP gender and number of patients Just over 40% of GPs said they had attended seen per week were related to the dependent vari- CPD on overweight and obesity. We found no sig- ables, and hence were adjusted for in the logistic nificant association between attending CPD and the regression modelling. number of patients counselled (Table 2). However, the proportion of GPs feeling professionally well prepared to manage adult overweight and obesity Results was higher in those who attended CPD (82%) than in those who did not attend it (74%; odds ratio GP characteristics (OR) = 1.56; 95% CI = 1.04, 2.33; p = 0.03). Respec- tive percentages were 52% and 33% for childhood Characteristics of the responding GPs are presented overweight and obesity (OR = 2.19; 95% CI = 1.58, in Table 1; 58% were male, on average they had 3.03; p < 0.001). 192 L.M. Buffart et al.

Table 2 GP knowledge, confidence, role perception and practice in regard to managing overweight and obesity in adult and child patients Total group Subgroup by number of Logistic regression (n = 646) patients counselled per week analysesa Adults: ≥10 Adults: <10 Odds ratio p-Value patients (n = 234) patients (n = 407) (95% CI) Attended CPD on 269 (42) 110 (47) 158 (39) 1.44 (0.93, 2.24) 0.102 overweight and obesity, n (%) yes Knowledge Only a small percentage 301 (47) 109 (47) 192 (47) 1.14 (0.74, 1.76) 0.540 of adults can reduce BMI and maintain that loss for at least a year, n (%) agreed Role perception The best role for a GP is 49 (8) 15 (7) 34 (8) 0.84 (0.42, 1.69) 0.633 to refer overweight and obese adults to other professionals rather than attempting to treat them, n (%) agreed Confidence I am professionally well 497 (77) 199 (85) 298 (73) 2.69 (1.49, 4.87) 0.001 prepared to manage adults who are overweight or obese, n (%) agreed Total group Subgroup by number of Logistic regression (n = 646) patients counselled per week analysesa Children: ≥3 Children: <3 Odds ratio p-Value patients (n = 232) patients (n = 408) (95% CI) Attended CPD on 269 (42) 111 (48) 156 (38) 1.42 (0.91, 2.21) 0.123 overweight and obesity, n (%) yes Knowledge Only a small percentage 211 (33) 84 (36) 126 (31) 1.21 (0.77, 1.89) 0.409 of children can reduce BMI and maintain that loss for at least a year, n (%) agreed Role perception The best role for a GP is 133 (21) 42 (18) 91 (22) 0.72 (0.43, 1.22) 0.223 to refer overweight and obese children to other professionals rather than attempting to treat them, n (%) agreed Confidence I am professionally well 264 (41) 130 (56) 134 (33) 3.31 (2.10, 5.22) <0.001 prepared to manage children who are overweight or obese, n (%) agreed CI: confidence interval; CPD: Continuing Professional Development; GP: general practitioner; BMI: body mass index. a Adjusted for GP’s gender and the number of patients seen per week. Obesity management in general practice 193

Discussion undertaking assessment of weight and adiposity, delivering brief advice, and motivating behaviour This study found that a large proportion of GPs change through goal setting and regular follow- believed that patients, particularly children, can up, are topics that could be addressed in CPD [9]. reduce BMI and maintain that loss, and the majority The example of the UK primary care Counterweight saw it as their role to assist in this process. The per- program indicates that only up-skilling clinicians ceived role of GPs in managing rather than referring without other strategies did not improve weight adult patients is consistent with the results from a loss outcomes [19]. This implies that strategies GP survey in 2000 using similar questions [9]. This is to increase GP’s counselling behaviour should go also consistent with the reported views of patients beyond providing information only. A comprehen- who believe that GPs have an important role in sive approach to engage clinicians to change clinical weight management and are the preferred source practice and to empower patients to change their of information and advice about this issue [18]. lifestyle seemed to be promising [19]. Nevertheless, we found that only a small pro- Several limitations must be taken into account portion of GPs regularly provide counselling on when interpreting the results of the study. The overweight or obesity. The present study indicates response rate was 40% and, while similar to that that this discrepancy may partly be caused by GPs’ achieved in recent surveys of GPs [20,21], may confidence in managing overweight and obesity, hamper generalizability of the study. It is possi- as those GPs who felt more confident were more ble that respondents were those most interested likely to counsel. However, it was also evident that in management risk factors for chronic diseases or the percentage of GPs who regularly counselled in research methods in general, which may have adult patients was much smaller than the percent- led to an overestimation of confidence and coun- age who felt confident to do so, suggesting that selling. The strength of the current study was that additional factors are determining whether or not all registered GPs in several rural and urban areas overweight and obesity is addressed in patient care. were approached, which formed a good representa- Time and structural constraints, such as reimburse- tion of New South Wales practices. Another source ment schedules or practice support systems, are of bias leading to overestimation of results could likely to be influential [9,13,14]. have been the use of self-reported measures which Among these GPs we have found fewer who are susceptible to social desirability and recall bias. engaged in counselling for weight management Again, the likely consequence of this is that the than for physical activity, as 47% of them reported findings represent a best-case scenario concerning providing counselling to more than 10 adults per GP beliefs and practices related to the management week on physical activity [12], and only 36% on of overweight and obesity. weight management. The lower proportion of GPs In conclusion, the present study showed that providing counselling on overweight and obesity although the majority of GPs see it as their role compared to physical activity is accompanied by to manage overweight and obesity, only a small a slightly lower confidence in weight management proportion of patients are counselled. Low coun- counselling. Furthermore, the greater complex- selling rates may be the result of GPs confidence ity of weight management, including psychological in managing patients, particularly children. CPD on issues, lack of time for regular monitoring of overweight and obesity may have positive effects patients who need to reduce their weight, and neg- on GP confidence, but to increase counselling ative perceptions of overweight and obese patients behaviour, additional strategies including changes may play a role [14]. of clinical practices and empowering patient are Only 41% of GPs reported that they were necessary. confident in managing paediatric overweight and obesity. Lack of experience in counselling obese children and their families may be an important factor here. Furthermore, difficulties exist with Conflict of interest recognizing overweight in children [10], communi- None declared. cating with parents about children’s weight [3], and intervening in relation to family influences [3]. The present study indicated that under half of GPs reported attending CPD on weight manage- Acknowledgments ment, indicating that there is scope for further training of GPs especially in relation to children. Funding of the survey field work was partly Skills in working with parents and families [17], supported by the National Heart Foundation of 194 L.M. Buffart et al.

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