Correspondence:
Dr. Mohamed Ghaith Al-Kuwari
Senior Specialist in Family Medicine
Primary Care- Hamad Medical Corporation
Doha- Qatar
P O Box 3050
Tel: +974- 5514962,
P O Box 5054
e-mail: drmgalkuwari@gmail.com

The World Health Organization (WHO), despite its historical focus on malnutrition, has for the first time recognized the problem of obesity. The organization called for urgent action to combat the growing epidemic of obesity, which now affects developing and developed countries alike.^1,2 In 2000, there were an estimated 300 million obese adults worldwide. In developing countries, it is estimated that over 115 million people suffer from obesity-related problems and a rapid increase in childhood obesity has also been reported.^3,4

In general, obesity is associated with a greater risk of disability and/or premature death due to type 2 diabetes mellitus, cardiovascular diseases such as hypertension, stroke and coronary heart disease, gall bladder disease, certain cancers (endometrial, breast, prostate, colon) and non-fatal conditions such as gout, respiratory conditions, gastro-esophageal reflux disease, osteoarthritis and infertility. Obesity also carries serious implications for psychosocial health, mainly due to societal prejudice against fatness.^5,6

Most health organizations recommend that physicians assess their patients for overweight, develop weight management plans tailored to patient's needs including referring patients to ancillary personnel when appropriate, providing monitoring, support and encouragement.^7,8 Moreover, patients should receive appropriate counseling about safe weight management and the benefits of lifestyle modification (physical activity and healthy diet).

Because of high patient contact rates and the perceived creditability of physicians by the public, primary care physicians have been identified as an important and cost-effective contributor to treatment and prevention of overweight and obesity by counseling their obese patients and promoting healthy lifestyle.^9,10 However, it has been documented that many obese and overweight patients receive no advice on weight loss during primary care visits.¹¹

In Qatar, prevalence of obesity and overweight are increasing in both adults and children. WHO estimates that 29.3% of females and 17.4% of males are obese.¹² Moreover, a Qatari study showed that the prevalence of overweight and obesity was 28.6%, and 7.9%, respectively, among adolescent boys and 18.9%, and 4.7% among girls.¹³ In primary health care centers in Qatar, most of the obese patients are presenting with common preventable co-morbidities e.g. Diabetes Mellitus, Hypertension, Dyslipidemia and Osteoarthritis. Obesity management can prevent occurrence of such illnesses or at least can improve the clinical course of it. In Qatar, there is not enough accurate data about the assessment of knowledge, attitude, and practice of primary care physicians towards obesity management. This study aims to assess primary care physicians' knowledge, attitude, and practice related to obesity management in Qatar.

The State of Qatar, is located in Arabian Gulf, and is one of the GCC countries with a population more than 796,000 estimated last census in 2005. Primary heath care in Qatar is provided through a network of 24 primary health care centers distributed all over the country. There are 253 physicians working at these centers. This cross-sectional survey has recruited primary care physicians working in primary health care centers in Qatar in the last 3 months. Sample size is calculated using 253 physicians. These include family medicine board certified and other non-family medicine certified physicians. Assuming 10% losses due to refusal and other reasons, we arrived at 136 physicians.

The following formula was used
N= Nz²p (1-p) l [d²(N-1)+z²p (1-p)]

In which; N = total population (253); z = value corresponding to the confidence level (1.96²=3.84); d = absolute precision (0.05²=2.5); p = proportion of the population with the studied characteristics (0.2). Subjects will be recruited by using "Simple random sampling Technique". A list of Primary Health Care physicians will be considered as sampling frame and each physician will be considered as a unit. 136 physicians were randomly selected from the list.

A structured self-administered questionnaire was used to collect data from the primary care physicians. The questionnaire was in English and had four main parts: personal data knowledge, attitude and practice. Personal data includes age, gender, position, last qualification and year of graduation. Knowledge about obesity management includes 10 statements testing knowledge about health risk of obesity, diagnosis, lifestyle (nutrition, physical exercise) and source of knowledge.

Answers were categorized into (Yes, No, I don't know). Attitudes associated with obesity, obese patients, effectiveness of obesity management and role of physician was tested with 7 statements where the answers were categorized into (agree, neutral, disagree). Practicing obesity management in the last 3 months was clarified with 8 statements about diagnosis, advice, management (part of comorbidity management or prevention), referral and receiving training. Answers were categorized into (always, sometimes, rarely, and not at all). Data were coded and entered into Statistical Package of Social Science, version 13.00 for windows (SPSS-13).

Knowledge
Of the 136 questionnaires distributed, 118 were returned; representing a response rate of 86.7 %. Table 1 presents the profile of GPs who participated in the survey. Mean age was 42.2 years (SD 7.2, range 30-59). Sixty-four physicians were females (54.2 %) and 54 (45.8%) were males. Among these categories, only 28% were Qatari and 39 % were family board certified physicians. Regarding experience in clinical practice, 28 % had less than ten years and 26.3 % had more than 20 years. Only 16 participants (13.6%) have received training in obesity management.

Table 2 presents participants' knowledge regarding obesity and its management. About 88 of the respondents (74.6%) were aware of the correct definition of obesity, BMI =30 kg/m2 and 88 (74.6%) correctly identified abdominal obesity as waist circumference >102 cm for males and >89 cm for females. Regarding diseases associated with obesity, about 55.9% and 47.4% of physicians were aware that obesity is associated with colon and endometrial cancer respectively. While 51.7 % knew that it is associated with Breast cancer, and 61.8% were aware that obesity is associated with osteoarthritis.

In terms of factors contributing to obesity, 86.4% of participants identified hormonal abnormalities as a determinant for obesity. Whereas, 71.1% identified genetic factors and 70.3% psychological status, as predisposing factors for obesity. Only 50.8% knew that low socioeconomic status is one of the determinants for obesity.

Regarding knowledge about obesity management, three quarters of participating physicians (75.4%) were aware that overweight patients should be encouraged to reduce their weight. However, only 22% of them were aware that weight reduction medication is indicated if overweight patients failed to reduce more than 10% of their weight after three months of supervised dietary and physical activity program in the absence of any other risk factors for cardiovascular disease. On the other hand less than a third of them (29.6%) were aware that a diet for weight loss should be high in carbohydrate and low in fat.

Attitudes to overweight and obesity management
Regarding attitudes toward obesity and obese patients, almost three quarters (74.6%) of physicians regarded obesity as a disease and (66.9%) considered overweight and obese patients lazier than normal weight people. Moreover, (64.4) % of them thought that overweight people lack willpower and motivation to reduce weight, as shown in Table 3.

More than two thirds of physicians (66.9%) agreed that the role of the primary care physician is not only to refer obese patients to other specialized care. More than half of the physicians (54.2%) regarded obesity management as professionally gratifying. However, only one third of them (33.9%) considered that they are professionally well prepared to manage obesity, and (66.9%) acknowledged that counseling in weight reduction is not easy.

Practice
Table 4 summarizes physician's approach to weight management. The majority of the physicians gave their patients advice on dietary habits (82.2%) and physical activity (80.5%). The majority of them (83.9%) offer weight control advice for patients with chronic illness e.g. DM or Dyslipidemia as part of their management.

Only seven participants (5.9%) stated that they prescribe drugs for weight management. Twenty-one physicians (17.8%) reported that they always refer their obese patients to others who specialized in obesity management. More than one quarter(28.8%) of the physicians stated that they always give their obese patient leaflets on weight reduction.

Regarding the usage of diagnostic methods for obesity; BMI was the most commonly used method by the physicians (67.8%), whereas (35.9% & 22.9%) always measure waist circumference and waist hip ratio respectively.

This study examined the knowledge, attitude, and practice in obesity management among primary care physicians. As such, this study provides valuable information about current obesity management at primary care level in Qatar.

The present results indicated deficiency in knowledge regarding obesity, especially at a basic knowledge level like the definition, predisposing factors and comorbidity. Nearly 25% of physicians were not aware of the widely used definitions of obesity.
We found that many primary care physicians were not aware of some diseases that are associated with obesity like osteoarthritis, colon and breast cancer; as well as the predisposing factors for obesity. This deficiency in knowledge reported by this study agreed with several studies that have shown that GPs knowledge about management of obesity is incomplete and thus express the need for clinical guidelines and supplementary training in obesity management as a part of residency and continuous medical education training.^14-17

Health professionals too often hold negative or stereotypical attitudes toward their obese patients such as: 'obese patients lack self control, lack motivation and are lazy'.^18-20 In this study almost two thirds of primary care physicians held theses negative attitudes toward obese people compared to less than one third of GPs in France.²¹

Although such attitudes seem less prevalent among health professionals than they were 30 years ago they are still held by 30% of GPs, internists, cardiologists and by a lower fraction of endocrinologists^18,19,21,22 and their prevalence tends to increase with patient BMI.^23,24 Another study found a relatively high rate of clear stigmatization and in some cases discrimination by health care professionals, which agreed with documented discrimination against obese individuals, especially in the fields of employment, education and health care.²⁴

Such a negative attitude toward obese patients may impede GP and patient interaction and result in perceived helplessness for both parties.^19,26,27 One of the probable explanations for this negative attitude is the low levels of knowledge and skills regarding obesity management.²⁸

On the other hand our study has shown a positive attitude of physicians toward their role and effectiveness in managing obesity. Similar positive attitudes have been found among Kuwaiti, Australian, Israeli and French GPs. However, about two thirds of participants in this study addressed the issue of difficulty in managing obesity which is consistent with the findings in other studies.^18,21,28,29 Similarly, a survey among Australian GPs revealed that most GPs considered practicing dietary and physical activity assessment and advice for overweight patients to be very important, although they acknowledged that sucha role was least likely to be practiced because they have inadequate nutrition knowledge and obesity counseling skills.^20,30 The importance of GPs in managing obesity is also recognized by patients, as patients' surveys have shown that they hold similar positive attitudes toward GPs' role in managing obesity.³¹

The study has shown that advice on dietary habits and physical exercise is the most common practice in obesity management among primary care physicians in Qatar. However the level of practice is lower than what has been reported in other research.¹⁸ For instance compared to 95% and 99% of GPs in Israel and United States are advising on physical activity as a part of managing obesity in their practice, only 80% of GPs in Qatar advising on physical activity.^18,32 And compared to 97% of American GPs and 92% of German GPs advice on dietary change, about 82% of GPs in Qatar do this as a part of their obesity management practice.^32,33 It is reported that some primary care physicians don't discuss lifestyle issues with their patients due to a number of issues such as time constraints, fear of negative reactions, or lack of training.^34,35

Consistent with findings of previous studies, GPs in Qatar tended to give advice to those who are obese and have obesity-related comorbidities such as type 2 diabetes, high cholesterol, or arthritis, as apart of their management for the chronic illness.^14,36 It is well known that the physicians are more likely to provide weight control advice to their patients who had obesity-related comorbidities to patients who were overweight or obese and without risk factors.^36,37 And such advice is associated with a greater likelihood of trying to lose weight.³⁸

Our study revealed that only 5.9% of primary care physicians prescribe anti obesity drugs compared to 39% among Korean.³⁹ This low percentage is also reported by Middle East countries, like Kuwait and Israel (3% & 4% respectively).^18,29 The low prescribing level can be attributed to unavailability of these drugs in primary care, and the concerns about the potential adverse effects may outweigh the health benefits of weight reduction. In addition to that, several studies showed that GPs regarded promoting healthy lifestyle as more useful than those drugs in obesity management.^28,40

In Qatar, obesity was mainly diagnosed by using BMI, which alone is not a sufficient predictor of risk of co-morbidities. There is more and more evidence that waist circumference or the waist: hip ratios are useful indices of abdominal fat accumulation and a better correlation with ill health and risk of coronary heart disease.^5,41,42

In conclusion, Primary Care physicians in Qatar felt that management of weight problems was one of their responsibilities. However, their knowledge about obesity management needs to be improved to affect their practice and attitude positively toward the obese individuals. This requires improvement in training of GPs in counseling their obese patients, and focusing on methods of giving dietary and physical activity advice regardless of the presence of comorbidities. Development of guidelines for obesity management in primary care is essential to help the GPs to practice obesity management on a standardized level.

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