Knowledge about epidemiological determinants of obesity and its management amongst medical professionals of Marathwada region of Maharashtra, India

INTRODUCTION

Obesity has become a challenge in medical care worldwide.¹ Obesity is perhaps the most prevalent form of malnutrition, prevalent in both developed and developing countries.² Worldwide obesity has nearly tripled since 1975. In 2016, 39% of adults aged 18 and over were overweight and 13% were obese. Most of the world population live in countries where overweight and obesity kills more people than underweight.³ Obesity may be defined as an abnormal growth of the adipose tissue due to an enlargement of fat cell size (hypertrophic obesity) or an increase in the fat cell number (hyperplasic obesity) or combination of both.⁴ The biological basis for weight regain has been documented in the medical literature for over 20 years.⁵ Obesity is a sequela to an abnormal obesogenic environment and is best tackled with extensive environmental interventions, supported by appropriate policy and legislation.⁶

Patients who are obese are also at increased risk for many other chronic diseases, including hypertension, diabetes, ischemic heart disease, gallstones, osteoarthritis and malignancy, as well as physical disabilities.⁷ Weight bias has serious consequences at the psychological, medical and social levels.⁸ Parameters commonly used to measure overweight and obesity are the Body Mass Index (BMI), Waist Circumference (WC) and Waist-Hip Ratio (WHR).⁹ The pandemic of overweight and obesity in developed and developing countries presents a challenge to public health and requires medical intervention, modifications of individual behavior, and environmental changes.¹⁰ Physician-level barriers to obesity care have been extensively explored in the literature. Many of the physician-level barriers relate to clinical knowledge and attitudes towards obese patients including: inadequate training in weight counseling, poor knowledge of the tools needed to diagnose and treat obesity.¹¹ Secondary as well as primary prevention is an essential part of primary care physicians work in accordance with the current recommendations.¹²

Medical professionals were expected to have sufficient knowledge on the epidemiological determinants, prevention and management of obesity. Therefore, they are expected to play an imperative role in limiting the increasing number of this lifestyle disorder of human and in promoting health education in India. Hence keeping this in mind, the present study was carried out to assess the knowledge regarding epidemiological determinants of obesity and its management amongst medical professionals of Marathwada region of Maharashtra, India.

METHODS

A cross-sectional study was carried out during the period of March 2019 to April 2019 amongst 110 medical professionals at Department of Community Medicine of IIMSR Medical College, Badnapur, District Jalna, Maharashtra, India who were actively participated in one day continued medical education (CME) on obesity and its management where the knowledge of medical professionals were assessed. CME consists of educational activities which serve to maintain, develop, or increase the knowledge, skills and professional performance and relationships that a physician uses to provide services for patients, the public or the profession.

On the day of study i.e., on 19^th March 2019 as the CME on obesity and its management was organized by Department of Community Medicine in collaboration with Medical Education Unit (MEU) of IIMSR Medical College as an academic feast. There were total 112 medical professionals (medical personnel’s who possess MBBS and above qualification) present and filled the questionnaires, out of which one was returned unfilled and one was incomplete, that’s why they were excluded from the final analysis; at final 110 questionnaires were filled complete and included in the study and accordingly data was analyzed. A pre‑designed, pre‑tested, self‑administered questionnaire in English was devised to collect data. The demographic details like age, gender, religion and residence status of the respondents were also recorded.

An 18‑item questionnaire was constructed to assess the knowledge as regards to epidemiological determinants, prevention and management of obesity, based upon a review of literature and similar studies conducted elsewhere.^5-7 All questions were close ended. Each correct answer was given 1 score and the range of the score varied between 0 (with incorrect answer) and 18 (for all correct answers). A scoring mechanism was used to understand the overall knowledge level; a score of one was given for each correct response and zero for each wrong response. Respondents with all correct responses get a maximum of 18 points, and higher points indicate good knowledge. Based on total score, knowledge level on obesity was categorized into poor (≤6 points), average (7‑12 points), and good (≥13 points). The medical professionals were explained and informed regarding the purpose of the study and the questionnaire was administered to them after obtaining the requisite permission from the head of the institution. The study was approved by the Institutional Ethics Committee. Participants were requested to complete the questionnaire, without discussing it amongst themselves. A pre- and post-test was conducted before commencement and after completion of CME on obesity and its management respectively. Data was entered in Microsoft Excel sheet and analysis of pre and post-test questionnaires was done by using appropriate statistical test whenever necessary.

RESULTS

As Table 1 shows that the demographic characteristics of study population, where more than half (52.7%) of study population was having age between 35-45 years followed by 23-35 years (29.1%). Male participants were more (67.3%) as compare to females (32.7%). Maximum number of study population (65.5%) belongs to Hindu community followed by Muslim (32.7%) and only (1.8%) was Christian. Majority (63.6%) of study population was from urban areas and (36.4%) were from rural areas.

It was seen from Table 2, the distributions of the knowledge score in pre and post-test. In pre-test good knowledge score was 14 (12.7%) and after CME it was increased to 61 (55.5%). There was marked improvement in level of knowledge regarding obesity after CME completion as compare to previous knowledge amongst study population.

It was evident from table 3 that the score of level of knowledge among study population, in pre-test the mean score was 7.41±4.12 and after the completion of cme the mean score increased to 5.49 and it was 12.90±5.21.

This shows that there was significant improvement in knowledge of study population after Continued Medical Education (CME) on different aspects of obesity.

(*Correct answers; Figures in parentheses indicate percentages).

As Table 4 shows that comparison between pre and post-test knowledge regarding obesity and its management among study population, in pre-test 84 (76.4%) subjects written correctly range of normal BMI and in post-test all written correctly, obesity is a public health problem worlwide was strongly agreed by 108 (98%) study subjects later on all accepted it as in post-test. There was improvement in knowledge of study subjects regarding main cause of obesity from 98 (89.1%) in pre-test to 107 (97.3%) in post-test. As regards awareness of leptin resistance, 75 (68.1%) individuals knew about it in pre-test and after CME it was 100 (90.9%) answered correctly. In pre-test 87 (79.1%) participants knew obesity is a chronic inflammatory disease and 106 (96.4%) written correctly in post-test. With respect to cut-off level of waist circumference, 71 (64.5%) participants knew the correct value in pre-test and 103 (93.6%) participants answered it correctly in post-test. About 65 (59.1%) individuals knew that functional residual capacity is affected in obese patients and 103 (93.7%) participants knew in post-test. As regards recommended weight gain in pregnant women, 64 (58.1%) participants knew the correct value in pre-test and after CME, 101 (91.8%) participants answered it correctly. Knowledge was also improved regarding cause of childhood obesity, effect on puberty, bariatric surgery, anti-obesity drugs, anesthetic and gynecological aspects of obesity.

DISCUSSION

In the present study, obesity was recognized as public health problem by 108 (98.1%) of study participants. Similarly a study done by Mkhatshwa et al showed that, 97.5% participants were aware that overweight and obesity are public health problems in South Africa.⁹ Another study by Metcalf et al found that 92% of physicians agreed with the statement that the obesity is a big health problem among children and adults.⁷ A study by Tsai et al also found that obesity was well recognized as a public health problem by 95.7% participants.⁵ A study done by Bocquier et al in general practitioners showed that who had taken a CME course and were aware of weight control guidelines felt more effective, probably because this training increased their self-confidence.¹⁰

In this study, obesity is a chronic inflammatory disease stated by 87 (79.1%) of study participants, similarly a study by Tsai et al also found that 71% participants were aware obesity as chronic illness.⁵

In this study, 84 (76.4%) participants knew the definition of obesity and BMI calculation method. Similarly a study done by Mkhatshwa et al showed that the definition of obesity and BMI calculation method was not known by one third of the participants.⁹ A study by Al Ghawai et al found that more than 60% of the participants did not know the classification of overweight and obesity according to BMI in their study.⁶ Related with the cause of obesity, 98 (89.0%) participants knew that it was because of increase energy intake and sedentary life style in the present study. Similarly, a study done by Tsai et al found that behavioural factors have high impact in weight regains than biological factors.⁵

Regarding obesity in Asian women, majority 71 (64.5%) participants knew that the cut-off value for the waist circumference is ≥80 cm. Similarly, a study by Sebiney also found that 60.8% study participants correctly identified the waist circumference.¹³

Regarding childhood obesity the commonest cause was environmental stated by 81% participants in this study. Similarly, a study done by Sahoo et al stated that the environmental factors such as school policies, demographics and parents work related demands further influence eating and activity behavior.¹⁴ Another study by Wilding J believes that changes in our environment are responsible for obesity.¹⁵

In present study, 78 (70.9%) participants were aware that bariatric surgery should be done irrespective of co-morbidity when BMI is greater than 40, as the rate of obesity continues to rise medical personnel must have knowledge about bariatric surgery, physician’s knowledge of bariatric surgery could be improved by establishing more opportunities for education, Similarly a study done by Auspitz et al also found that 92.5% of physicians would like to receive more education about bariatric surgery.¹⁶ The concern about health risks associated with obesity has led member states of the World Health Organization (WHO) to adopt a voluntary target to halt the rise in obesity by 2025. The management of obesity generally includes clinical counselling focused on diet, physical activity, behavior change, pharmacotherapy and bariatric surgery.

Limitations of this cross-sectional study was that the findings are from a single medical college and a certain group of population i.e., medical professionals only and as a small sample size; therefore, the findings cannot be generalized to all medical professionals or other healthcare professionals in the country.

CONCLUSION

The present study concluded that there was marked improvement in the knowledge regarding epidemiological determinants of obesity and its management amongst study participants after Continued Medical Education (CME). As obesity is a public health problem globally, there is need of hour to improve the knowledge regarding overweight and obesity amongst medical and paramedical personnel by conducting periodic CMEs, conferences or workshops.

ACKNOWLEDGEMENTS

Authors express their deep sense of gratitude to the Management, JIIU Trust and Dr. Amarnath B. Solepure, Dean, IIMSR Medical College, Badnapur, Dist. Jalna, Maharashtra for granting permission for this study. Authors also deeply acknowledge the help and support of all teaching faculty of Department of Community Medicine and all members of Medical Education Unit of IIMSR Medical College, Badnapur during this study. Authors also acknowledge the help of Mr. Pankaj R. Gangwal, Statistician, Department of Community Medicine of IIMSR Medical College, Badnapur during data analysis. Last but not the least, the authors express their sincere gratitude to all participants for sparing their valuable time to participate in this study.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

REFERENCES

1. 1. Martins C, Norsett-Carr A. Obesity knowledge among final-year medical students in Norway. Obes Facts. 2017;10(6):545-58.
2. 2. Park K. Textbook of Preventive and Social Medicine, 25^th ed. Jabalpur, M/s Banarsidas Bhanot Publishers; 2019: 426-427.
3. 3. World Health Organization (WHO) 2018. Obesity and Overweight, Fact Sheet No.311 2018:132-137.
4. 4. Hager A. Cumulated Index Medicus. Br Med Bull. 1981;37(3):287-89.
5. 5. Tsai AG, Histon T, Kyle TK, Rubenstein N, Donahoo WT. Evidence of a gap in understanding obesity among physicians. Obes Sci Prac. 2018;4(1):46-51.
6. 6. Al-Ghawi A, Uauy R. Study of the knowledge, attitudes and practices of physicians towards obesity management in primary health care in Bahrain. Pub Health Nutr. 2009;12(10):1791-8.
7. 7. Metcalf M, Rossie K, Stokes K, Tanner B. The perceptions of medical school students and faculty toward obesity medicine education: survey and needs analysis. JMIR Med Edu. 2017;3(2):e22.
8. 8. Bucher Della Torre S, Courvoisier DS, Saldarriaga A, Martin XE, Farpour-Lamber NJ. Knowledge, attitudes, representations and declared practices of nurses and physicians about obesity in a university hospital: training is essential. Clin Obes. 2018;8:122-30.
9. 9. Mkhatshwa VB, Ogunbanjo GA, Mabuza LH. Knowledge, attitudes and management skills of medical practitioners regarding weight management. Afri J Pri Health Care Family Med. 2016;8(1).
10. 10. Bocquier A, Verger P, Basdevant A, Andreotti G, Baretge J, Villani P, et al. Overweight and obesity: knowledge, attitudes, and practices of general practitioners in France. Obes Res. 2005;13(4):787-95.
11. 11. Bleich SN, Bennett WL, Gudzune KA, Cooper LA. National survey of US primary care physicians’ perspectives about causes of obesity and solutions to improve care. BMJ Open. 2012;2(6):e001871.
12. 12. Fogelman Y, Vinker S, Lachter J, Biderman A, Itzhak B, Kitai E. Managing obesity: a survey of attitudes and practices among Israeli primary care physicians. Int J Obes. 2002;26(10):1393-7.
13. 13. Sebiany AM. Primary care physicians’ knowledge and perceived barriers in the management of overweight and obesity. J Family Commun Med. 2013;20(3):147.
14. 14. Sahoo K, Sahoo B, Choudhury AK, Sofi NY, Kumar R, Bhadoria AS. Childhood obesity: causes and consequences. J Family Med Pri Care. 2015;4(2):187.
15. 15. Wilding J. Are the causes of obesity primarily environmental? Yes. BMJ. 2012;345:e5843.
16. 16. Auspitz M, Cleghorn MC, Azin A, Sockalingam S, Quereshy FA, Okrainec A, et al. Knowledge and perception of bariatric surgery among primary care physicians: a survey of family doctors in Ontario. Obes Surg. 2016;26(9):2022-8.