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Abstract
BOCQUIER, AURELIE, PIERRE VERGER, ARNAUD
BASDEVANT, GERARD ANDREOTTI, JEAN BARETGE,
PATRICK VILLANI, AND ALAIN PARAPONARIS.
Overweight and obesity: knowledge, attitudes, and practices of
general practitioners in France. Obes Res. 2005;13:787795.
Objective: To describe the current knowledge, attitudes, and
practices of French general practitioners (GPs) in the field
of adult overweight and obesity management.
Research Methods and Procedures: A cross-sectional telephone survey interviewed a sample of 600 GPs, representative of the private GPs in southeastern France. A four-part
questionnaire assessed personal and professional characteristics, attitudes and opinions about overweight and obesity,
relevant knowledge and training, and practices (diagnostic
methods, clinical assessments, weight loss objectives, types
of counseling).
Results: Most GPs knew that weight problems are healththreatening, and 79% agreed that managing these problems
is part of their role. Nevertheless, 58% did not feel they
perform this role effectively, and one-third did not find it
professionally gratifying. Approximately 30% had negative
attitudes toward overweight and obese patients; 57% were
pessimistic about patients ability to lose weight; 64% often
set weight loss objectives more demanding than guidelines
Introduction
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 (1). Epidemiological studies in France, Spain, and Italy have shown
this disease striking the Mediterranean area, where food
habits have long seemed to protect against cardiovascular
risks (2,3). General practitioners (GPs)1 have a significant
role to play in preventing and diagnosing weight problems
and in providing initial counseling (4,5). They are, after all,
the health professionals consulted most often (6), and most
patients believe that their GPs couldand wish they
would help them to lose weight (7). Nonetheless, GPs do
not manage overweight and obesity satisfactorily, as they
themselves recognize (8 11): they identify only about onehalf of their overweight or obese patients (1214) and
advise only one-third of these patients to lose weight
(1517).
787
GPs Attitudes and Practices about Overweight and Obesity, Bocquier et al.
Table 1. Demographic characteristics of the sample of respondents and of the population of private general
practitioners in Provence
General population of
GPs in Provence
(n 5435)
Sex
Male
Female
Age (years)
43
43 to 52
52
Size of practice area
(number of inhabitants)
2000
2000 to 200,000
200,000
Percentage
Percentage
2
tests
4140
1295
76.2
23.8
452
148
75.3
24.7
p 0.65
1398
2889
1148
25.7
53.2
21.1
158
305
137
26.3
50.8
22.8
p 0.50
357
1334
3744
6.6
24.5
68.9
52
150
398
8.7
25.0
66.3
p 0.13
Sample of
respondents
(n 600)
GPs Attitudes and Practices about Overweight and Obesity, Bocquier et al.
Results
GPs Characteristics
Most GPs (82.8%) practiced in the controlled billing
sector, and 55.4% practiced in group practices. Only 44.8%
subscribed to medical journals, 69.7% consulted guidelines,
47.8% had postgraduate medical degrees, and 15.7% were
involved in a health network. The prevalence of overweight
among GPs [30%; 95% confidence interval (CI) 26.3 to
33.7] was close to that of the French adult population
(29.4%; 95% CI 28.9 to 29.9), but the prevalence of
obesity was lower: 3% (95% CI 1.8 to 4.6) vs. 9.6% (95%
CI 9.2 to 10.0) (19). Approximately one-third of GPs had
dieted (84% lost weight); 71.5% considered their eating
habits to be healthy; 76.9% reported exercising at least
weekly; 69.9% were currently monitoring their food intake
to lose or maintain weight; and 26% were current smokers.
GPs Attitudes Toward Overweight and Obesity
Most GPs regarded obesity as a disease and agreed that
their role includes weight problem management, but 57.5%
felt that they do not manage it effectively. Approximately
30% considered overweight and obese patients lazier and
more self-indulgent than normal weight people, and 57.2%
were rather pessimistic about these patients ability to lose
weight (Table 2).
The multiple logistic regression (Table 3) showed that
practice in the noncontrolled billing sector (p 0.01), CME
training about weight problems (p 0.01), awareness of
obesity management guidelines (p 0.02), normal weight
(p 0.05), and personal success in losing weight (p 0.01)
were associated with a feeling of effectiveness in this field.
Negative attitudes toward obese patients were associated
with not subscribing to any medical journals (p 0.03),
awareness of obesity management guidelines (p 0.03),
and never having dieted themselves (p 0.05; Table 3).
GPs rated food intake as a significantly more important
risk factor for obesity than stress, hormonal problems, or
unemployment. They also rated the medical consequences
of obesity as more important than its psychological and
social consequences (Table 4).
GPs Knowledge and Training in the Field of Weight
Control
Most GPs (51.2%) underestimated the prevalence of
overweight in the French adult population, whereas one-half
overestimated the prevalence of obesity. Nearly all recogOBESITY RESEARCH Vol. 13 No. 4 April 2005
789
GPs Attitudes and Practices about Overweight and Obesity, Bocquier et al.
Strongly
disagree
Rather
disagree
Rather
agree
Strongly
agree
Obesity is a disease
Normal weight is important for health
For overweight and obese patients even small weight
loss can produce health benefits
Most overweight patients should be treated for
weight loss
Only obese patients should be treated for weight loss
Obesity management is necessary in the long term
GPs role is to refer overweight and obese patients
to other professionals rather than attempt to treat
them themselves
GPs should be models and maintain normal weight
I feel well prepared to manage overweight and obese
patients
Treating overweight and obese patients is
professionally gratifying
Obese people are lazier and more self-indulgent than
normal weight people
Overweight people are lazier and more self-indulgent
than normal weight people
Only a small percentage of overweight and obese
people can lose weight and maintain this loss
595
599
2.5
0.7
7.2
0.2
33.4
16.9
56.8
82.3
596
0.0
0.8
21.5
77.7
598
595
598
0.8
40.2
0.2
5.9
39.8
0.3
47.5
14.6
15.9
45.8
5.4
83.6
594
595
31.0
7.7
48.0
8.7
17.5
53.1
3.5
30.4
596
5.9
26.5
44.6
23.0
595
7.6
23.9
48.4
20.2
597
27.3
41.9
26.1
4.7
594
25.9
45.5
24.9
3.7
597
11.9
30.8
48.2
9.0
nized most health consequences of obesity (premature mortality, type II diabetes, sleep apnea, hypertension, increased
surgical risks, phlebitis), but 53% were unaware of the risks
of infertility, and 45.5% were unaware of the risks of some
cancers. Only 6.7% were aware of the guidelines for obesity
management. One-half reported that their main source of
information in this field was medical journals, 25.2% was
CME, and 10.4% was experience described by patients. Just
over one-half of the GPs (54.2%) had taken a CME class in
weight management, and 80% acknowledged they needed
more training, especially about nutrition counseling and
behavioral therapy.
GPs Practices
Most GPs (88.5%) often or always used BMI as a diagnostic method, whereas only 41% often or always measured
the waist (Table 5).
More than 90% of the participants often or always assessed
individual risk factors, physical activity, dietary habits, patients expectations and motivation, patients psychological
790
state, existence of food behavioral problems, and weight history; a lower but still high proportion (70% to 90%) often or
always assessed respiratory problems, venous and lymphatic conditions, joint diseases, calory intake, energy expenditure, and social status; 60% to 70% often or always
checked for hepatomegaly or steatosis, sleep disorders, and
pain; and 30% to 40% often or always assessed skin condition and looked for cancerous breast nodules.
One-half the sample (50.8%) set a loss of 5% to 15% of
initial weight as the objective for overweight patients. To
reach this goal, 23.2% often or always prescribed drug
treatment, 31.6% recommended psychotherapy, 14.8% recommended a behavioral therapy, and almost one-half included a spouse or a close relative in the treatment. Too
stringent treatment objectives for obese patients were set
by 64.3% of GPs (weight loss to normal BMI or 15%;
Table 6).
Nearly all participants (90% to 99%) gave traditional
nutritional advice (Table 5). Only 35% often or always
counseled avoiding specific foods, and 22% suggested very
GPs Attitudes and Practices about Overweight and Obesity, Bocquier et al.
Table 3. Determinants of GPs feelings of effectiveness and attitudes towards obese people (multiple logistic
regression with sex and age forced; Provence, 2003)
Model 1: feels effective in
management of weight
problems (n 578)
OR
Billing sector
Controlled billing sector
1
Noncontrolled billing sector
1.94
Medical journal subscription
Yes
No
Has taken a CME class about management of
weight problems
Yes
1.66
No
1
Knows guidelines for obesity management
Yes
2.35
No
1
Current BMI (kg/m)
Underweight or normal range (25)
1
Overweight (25 to 29.9)
0.59
Obese (30)
0.71
Has ever been on a diet
No
1
Yes and it succeeded
1.91
Yes but it failed
0.94
Hosmer-Lemeshow test
p 0.31
95% CI
p (Wald)
95% CI
0.67
1
0.46 to 0.96
p (Wald)
0.01
1.22 to 3.08
0.03
0.00
1.17 to 2.36
0.02
1.13 to 4.86
0.03
2.15
1
1.10 to 4.20
0.05
0.39 to 0.90
0.24 to 2.13
0.01
1.25 to 2.91
0.38 to 2.32
0.05
1
0.64
0.55
p 0.95
0.41 to 0.98
0.16 to 1.17
Variables statistically not significant in univariate analysis: 1) any model: sex, age, solo/group practice, guidelines use, belongs to a health
network, postgraduate medical degrees, is currently monitoring his food intake, tobacco status; 2) model 1: medical journal subscription,
reports regular physical activity; 3) model 2: billing sector, CME class, current BMI, reports a healthy diet.
Variables statistically significant in the univariate but not the multivariate analysis: 1) any model: size of practice area; 2) model 1: reports
a healthy diet; 3) model 2: reports regular physical activity.
OR, odds ratio.
Discussion
We found that most GPs believed their role in overweight
and obesity management is important but did not feel that
they performed it effectively. This observation is consistent
with results of other studies of GPs (8,9,11) and also,
OBESITY RESEARCH Vol. 13 No. 4 April 2005
791
GPs Attitudes and Practices about Overweight and Obesity, Bocquier et al.
Risk factors
Eats too much fat
Eats too much
Eats too much sugar
Insufficient physical activity
Genetic factors
Repeated dieting
Stress. anxiety, and depression
Hormonal problems
Low income, unemployment
Consequences
Medical problems
Psychological problems
Social problems
Success indicators in weight problems
management
Adoption of healthier diet and
exercise habits
Weight loss to the normal BMI
range
Improvement of body image and self
confidence
Even small weight loss but longlasting
Improvement in clinical indicators
Mean*
SD
5.2
5.1
4.9
4.7
4.5
4.2
4.1
3.7
3.3
0.93
1.02
1.01
1.08
1.25
1.26
1.07
1.28
1.19
4.9
4.3
3.8
1.11
1.04
1.09
5.3
0.75
5.1
0.96
5.0
0.89
4.7
4.6
0.94
1.07
interestingly, of endocrinologists and internists (20). Several obstacles may explain this apparent contradiction.
Physicians and patients have different perceptive and
attitudinal models of weight problems, and one major obstacle may be the problem this creates in their relationship.
Our results suggest that GPs perceptions of overweight and
obesity are shaped by a model that blames the victim (21):
they perceive behavioral factors (food habits and physical
activity) as greater risk factors for obesity than genetic
792
GPs Attitudes and Practices about Overweight and Obesity, Bocquier et al.
Table 5. GPs practices in the field of adult overweight and obesity management (Provence, 2003)
Responses (%)
Practices
Diagnosis methods
Weight without reference to height
BMI
Waist/hips ratio
Waist measurement
Comparison with ideal weight (according to
Lorentz formula) (39)
Appearance
Weight management advice and tools
Eat less during meals
Eat less fat
Dont eat between meals
Eat less sugar
Eat more fruits and vegetables
Consume fewer caloric drinks
Definitely avoid specific foods
Follow personalized low-calorie diet (1200 to
2200 kcal/day)
Follow very-low-calorie diet (1200 kcal/day)
Follow commercial diet
Exercise (sports)
Do more exercise in everyday life (e.g.,
walking, gardening)
Leaflets on healthy behavior
Food diary
Nutritional education
Never
or rarely
Sometimes
Often
Always or
almost always
600
600
599
599
77.0
6.3
44.2
38.7
7.5
5.2
20.9
20.2
7.8
16.0
19.2
23.5
7.7
72.5
15.7
17.5
598
598
46.8
21.4
19.7
18.6
18.4
29.9
15.1
30.1
595
598
597
597
597
598
599
10.4
0.5
6.0
0.7
0.7
0.0
53.4
13.9
1.8
3.0
4.5
3.9
0.3
11.2
25.0
17.9
16.1
21.4
17.6
8.2
14.4
50.6
79.8
74.9
73.4
77.9
91.5
21.0
597
598
598
598
11.6
55.0
53.8
3.8
14.6
22.6
33.8
9.4
37.7
14.7
8.7
30.1
36.2
7.7
3.7
56.7
587
597
597
598
2.0
12.6
37.4
17.6
2.7
21.4
23.3
18.6
18.6
31.0
20.4
29.9
76.7
35.0
18.9
33.9
planations for patients, discussion of treatment and prevention, and health education require longer consultations. We
found GPs in the fixed-fee billing sector were less likely
to feel effective in overweight and obesity management.
The type of remuneration influences length of consultation
(36); therefore, GPs in this sector may have shorter consultations than the others.
GPs who had taken a CME course and were aware of
weight control guidelines felt more effective, probably because this training increased their self-confidence and convinced them that success is possible. The need for better
training in the field of weight control was recognized by
80% of the GPs in our panel and has been pointed out by
internists, endocrinologists (20), and gynecologists (37).
Analyses of potential associations between GPs age and
various practices and knowledge did not provide convincing
evidence that young GPs, who should have received better
OBESITY RESEARCH Vol. 13 No. 4 April 2005
793
GPs Attitudes and Practices about Overweight and Obesity, Bocquier et al.
2.2
1.4
50.8
34.3*
14.0
45.0*
33.0
19.3*
23.2
31.6
14.8
40.5*
48.8*
24.2*
48.9
60.2*
* p 0.001.
less, like specialists, including endocrinologists and internists, most believed their treatment was of limited effectiveness, and one-third reported dissatisfaction with it.
Obstacles to satisfactory management seem to include GPs
attitudes and opinions and to some extent inadequate practices. In particular, we found, in a relatively new observation, that GPs set weight loss objectives for obesity management that were frequently too stringent.
A current reform of the French health care system will
give GPs a central role in health education and prevention.
Their attitudes and knowledge may thus determine whether
they can maintain this role and perform it effectively. However, organizational aspects, especially remuneration for the
time needed to implement prevention and education, must
also be considered: for example, the institution of incentive
fees for consultations for preventive and education purposes
might be useful. Assessment of these measures would then
be necessary (38). Facilitating work cooperation between
GPs and medical auxiliaries (such as dietician) might also
improve prevention and management of weight problems.
Acknowledgments
This work received technical and financial support from
the Southeastern France Regional Union of Private Practitioners (URML PACA) through the Southeastern France
Regional Union of Health Insurance (URCAM PACA)
Funds for Quality in Ambulatory Health Care (FAQSV).
We thank Drs. C. Colette, C. Fischler, M. L. Frelut, P.
Garandeau, M. Gerber, J. C. Gourheux, Jouret, P. Y. Lussault, M. Pellae, M. Rousseaux-Romon, M. Tauber, and H.
Thibault for invaluable help and advice and Jo Ann Cahn
for editorial assistance.
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