Abstract

Background: As obesity has become one of the most common health problems in Saudi Arabia, the Ministry of Health launched an initiative as a part of KSA national transformation program aims to decrease the incidence of obesity and chronic diseases, by applying prevention strategies and provide proper management. Objectives: to explore the knowledge, attitudes, and practices of the joint program of family medicine candidates in Makkah regarding obesity management. Materials and methods: A cross sectional study was carried out among a representative sample of resident physicians of the joint program of family medicine Ministry of Health, Makkah city during January 2020. A self-administered validated questionnaire was used for data collection. It consists of four main sections; sociodemographic data, knowledge related questions, attitude related statements and practice related statements. Results: The study included 116 family medicine residents. Females represent 58.6% of them. Majority of the participants (98.3%) aged between 25 and 34 years. Obesity was reported among 13.8%; 8.6% class I and 5.2% class II. More than half of the family medicine residents (51.7%) had attended course or workshop about obesity and its management. More than half (57.8%) of the participants had good level of knowledge regarding obesity and its management, with the highest rate was observed among postgraduate year 2 (73.5%) whereas the lowest level was reported among those of PGY 1 (28.6%), p=0.003. Also, more than half (54.3%) expressed positive attitude towards obesity management, and this was steadily increasing with the advancing in residency level (p=0.016) and years of experience (0.011). Adequate practice regarding obesity management was observed among 61.2% of them. Obese residents had higher rate of adequate practice regarding obesity management, p=0.008. The commonest barriers faced by the resident physicians when managing patients with obesity were lack of training in obesity management (47.4%), lack of knowledge (45.7%), lack of effective referral system (39.7%) and lack of time (38.8%). Conclusion: Good Knowledge, positive attitude and adequate practice of the family medicine residents, Makkah regarding obesity and its management are moderate with some defective elements.

1. Introduction

Obesity and overweight are defined as an excessive or abnormal accumulation of body fat that may impair health; it occurs mainly due to energy imbalance between consumed calories and expended calories. To classify obesity the most commonly used tool is Body Mass Index (BMI), it is calculated by dividing weight in kilograms by height in meters squared (Kg/m²).

According to the world health organization (WHO), the person will be classified as normal weight if the BMI is less than or equal to 24.9 Kg/m² and diagnosed as overweight if the BMI is higher than or equal to 25 Kg/m². For obesity diagnosis, the BMI should be greater than or equal to 30 Kg/m^{2 1}.

The effect of overweight and obesity is very serious, as it is considered a major risk factor for many diseases, such as cardiovascular diseases, stroke, diabetes, musculoskeletal disorders (especially osteoarthritis), some cancers (endometrial, breast, and colon) ¹.

The prevalence of obesity and overweight worldwide have more than doubled since 1980.In 2014, more than 1.9 billion adults 18 years and older were overweight, among these over 600 million were obese. In 2013, 42 millions of children under the age of 5 years were overweight or obese ¹.

In Saudi Arabia, many studies have been conducted in the past decades to measure the prevalence of obesity and overweight. According to the Saudi Health Interview Survey (SHIS) conducted by Memish ZA et al., in 2013, with 10.735 participants, showed that the prevalence of obesity and overweight in individuals 15 years and older is 28.7% and 30.7% respectively, in total obesity and overweight affect 59.4% of population ². Another study conducted by Al-Nozha MM et al., between 1995 and 2000, examined 17.232 Saudi subjects stats that the overall prevalence of obesity is 35.5% ³.

As obesity has become one of the most common health problems in Saudi Arabia, the ministry of health launched an initiative as a part of KSA national transformation program aims to decrease the incidence of obesity and chronic diseases, by applying prevention strategies and provide proper management, in order to improve the community health status, and decrease the burden of the problem ⁴.

To achieve that it is essential to improve competency and skills of Family medicine training program candidates, as they are under training, and they will become the first line of defense against this problem.

Two studies have been conducted in KSA to evaluate the knowledge, attitude, and practices of primary care physicians about obesity management.

One study conducted in 2012 by Al-Khaldi et al. aimed to explore the knowledge, attitudes, and practice of PHCC physicians in Aseer region regarding obesity. The total number of responses was 294 out of 339. The most common barriers to providing good management for obesity at PHCC were lack of time, health education materials, guideline, and referral system. Majority of physicians showed a good attitude regarding obesity management; on the other hand, 64% of participants scored less than 7 points in the evaluation of knowledge, which showed inadequate knowledge. More than half of participants reported that they gave advice about the roles of diet, and exercise in the management of obesity. In conclusion, study revealed that PHCC doctors need more training to improve their knowledge and, skills to provide better care for obese patients ⁵.

Another study was conducted between December 2009 and March 2010 in the eastern region (Dammam and Al Khobar) by Al-Shammari YF et al. aimed to determine the attitude and practices among primary care doctors regarding obesity management. One hundred thirty physicians responded, and the result showed that 80% of them had a negative attitude toward obesity concept, also more than two third of them believe that primary care physicians play an important role in obesity management. The majority of physicians state that they gave their obese patients advices about dietary habits, and physical activities, and one-third of them believe that they are well competent for the management of obesity. The study concludes that there is a gap in the attitude about the management of obesity among Physicians in Eastern Saudi Arabia, also showed an adequate level of interest in participating in obesity prevention and management ⁶.

In New South Wales, there is one study conducted in 2007, aimed to evaluate general practitioners’ (GPs’) knowledge, role perception, confidence, and practices in overweight and obesity management. 646 GPs participated in the study the response rate was 40%. About half of the participant (47%) believed that weight reduction is difficult for the majority of people. Most of the GPs said that it is their role to manage overweight and obesity, and they feel confident to manage adult with obesity but not children. Those GPs who attend courses and workshops about obesity and overweight were more confident to deal with such cases. In the end, the study concludes that only a few numbers of GPs provide regular counseling to the patient about their weight, that is may due to their confidence level in managing obesity, also the study recommends providing additional training to improve GPs in this aspect, especially with children ⁷.

In 2005 a study published in the international journal of obesity, to document the attitudes and practices of French general practitioners regarding obesity management. 744 French GPs was participating in the study; out of them 607 participants responded. The results showed GPs have a high awareness that obesity is a serious medical issue, 90% of them considering obesity as a disease. 42% considered themselves well prepared to manage obesity, and 66% believe that weight loss is a difficult task to be achieved by the patients. The study participants do not consider collaboration with other health professional is a priority in obesity management. Only 34% of GPs believe that the currently available drugs are effective. In conclusions, French GPs need to improve their practice in obesity management ⁸.

An earlier cross-sectional study published in 2000 in the obesity research journal to document Australian GPs attitudes and practices regarding management and prevention of obesity and overweight. 1500 GPs included in the study; 752 questioners returned. The participant said that weight control and management is essential, and The GPs play an essential role in it. Moreover, they found themselves competence and well prepared to manage such cases. The GPs consider the assessment of dietary and physical activity habits and provide the proper advice about it is very important in weight control. Eventually, the researcher said there is an opportunity to improve the practice of obesity management in the PHCC, also providing the proper educational training is fundamental ⁹.

This study aimed to evaluate the knowledge, attitude and practice of Saudi Board Family Medicine residents in Makkah about obesity management, January 2020.

2. Methods

A cross sectional study was carried out.

Makkah is the holy city for all Muslims, as there is Al Masjid Al-haram (The holy mosque), and Al ka’aba which representing Qibla of Muslims in prays. It is located in the western area of Saudi Arabia, in a region called Makkah region.

There are many medical post-graduate training programs in Makkah, indifferent specialties. One of them is the joint program of family medicine which is a four years post-graduate training program, in Oct 2019 the duration decreased to 3 years conducting by the ministry of health, under the supervision of Saudi commission for health specialty, to graduate a well-trained family medicine physician.

The joint program of family medicine candidates in Makkah city, January 2020 constituted the study population.

1. Candidates in the joint program of family medicine - Makkah.

2. All training levels (R1, R2, R3, R4).

3. Both male and female.

4. All Saudi and Non-Saudi.

Candidates from family medicine program outside Makkah.

The total number of the joint program of family medicine candidates in Makkah, as provided officially by the program administration are 160 resident doctors.

Based on that, the sample size is 114 resident doctors, calculated by using Raosoft.com with a margin error of 5%, and confidence level 95%.

Each one of the participants who constitute the whole population was labeled with a natural number (1, 2, 3, 4,…. , etc.). The required sample was selected by simple random technique. the questionnaire was distributed among all selected participants.

A self-administered questionnaire was reviewed by tow consultants for validation, then distributed to all candidates involved in the study.

The investigator designed the questionnaire based on researches conducted in KSA to evaluate the knowledge, attitudes, and practices of primary care physician about obesity management ^{5, 6}. The questionnaire consists of four main sections: -The first section was about sociodemographic data, with some questions related to barriers facing management of obesity. The second section was knowledge related questions, this part consists of ten statements based on clinical guideline of obesity management published by SIGN ¹⁰. Participants were considered to have good knowledge if scored 70% and above of total score. The third section consisted of eleven attitude related statements. They were assessed based on a scale (agree, neutral, disagree, no comment). The responses of the participants were scored in a way that the higher the score, the positive the attitude (therefore, some statements were reversed). Total score and its percentage were computed for each participant and the median value was defined. Those scored below the median value were considered having negative attitude whereas those scored at or above the median value were considered having positive attitude. The last section contained seventeen practice related statements, and were assessed based on (Always, sometimes, never) responses. Responses of the physicians to practice statements were scored in the way that for appropriate practice (always=2, sometimes=1 and never=0) whereas for inappropriate practice (always=0, sometimes=1 and never=2). Total score was computed by summation of responses of the 17 statements and the percentage was computed its median value was estimated. Physicians scored below the median value of the percentage of practice score (52.94%) were categorized as inadequate group whereas those scored at median value or above were categorized as adequate group.

The questionnaires were distributed to candidates of the JPFM during the half day release course (HDRC) which is held every Tuesday in the center of the program during the study period which is one month. As there was large number of residents attending the HDRC at the same time, they were divided into four groups. Each group consists of 37 candidates and had their meeting in a different hall.

At the beginning of the lecture of the HDRC, the researcher himself distributed the questionnaires to the residents then collected back at the end of the lecture. During the 1^st and 2^nd weeks, he distributed questionnaires to groups A & B and groups C & D, respectively. If the participants were not completed, the researcher did the same procedure again during the next 2 weeks, till the targeted number was achieved.

Knowledge, attitude, and practices of obesity management.

Age, gender, training level, years of experience, BMI, training courses about obesity, and barriers

The Statistical Package for Social Sciences (SPSS) software version 25.0 was used for data entry and analysis. Since all variables were categorized, frequency and percentage were used to describe them. Chi-square test was applied to test for association between two categorical variables. Fischer Exact test was applied instead of chi-square test in case of small frequencies (i. e. one of more of the cells had expected frequency of less than 5). P values were considered statistically significant if they were less than 0.05.

A pilot study was conducted at the joint program of family medicine in Jeddah to test the questioner and apply the full methodology to check for gaps and defects. As a result, the questionnaire was clear and there was no need to make a significant change.

Ÿ Approval from the joint program of family medicine in Makkah was obtained.

Ÿ Permission from the Directorate of Health Affairs of the Holy Capital Primary Health Care was obtained (IRB Committee).

Ÿ Consent from the participants was taken through the sentence (By answering the questions of this questionnaire you are agreeing to participate in the study).

Ÿ All information was kept confidential.

3. Results

The study included 116 family medicine residents. Table 1 presents their demographic characteristics. Females represent 58.6% of them. Majority of the participants (98.3%) aged between 25 and 34 years. Postgraduate year 2 represents 29.3% whereas postgraduate 4 represent 20.7% of them. Years of experience ranged between one and four amongmore than half of the participants (57.7%).

As illustrated from Figure 1, obesity was reported among 13.8%; 8.6% class I and 5.2% class II. More than half of the family medicine residents (51.7%) had attended course or workshop about obesity and its management.

Majority of the resident physicians could recognize that weight management program should include physical activity program, dietary program and behavioral changes (98.3%), BMI isthe most commonly used diagnostic tool for obesity (96.6%), low level of activity and high caloric intake are the two most important risk factors for obesity (84.5%), Orlistat is considered the anti-obesity drug of choice (84.5%), BMI>40 kg/m²is the definition of sever or morbid obesity (82.8%) and BMI>35 kg/m² with co-morbidities is an indication for bariatric surgery (80.2%). On the other hand, only 19.8% of the physicians knew that 5-10 kg in one year is the target of weight loss to get health benefits and Propranolol and Clozapine medications may induce obesity. (Table 2)

Overall, 57.8% of the Family Medicine resident physicians had good level of knowledge (>70%) regarding obesity and its management as clear from Figure 2.

Residency level was significantly associated with knowledge about obesity and its management (p=0.003) as the highest rate of good knowledge was observed among postgraduate year 2 (PGY 2) (73.5%) whereas the lowest level was reported among those of PGY 1 (28.6%). Other studied factors (gender, age, years of experience, body mass index and history of attending course or workshop about obesity and its management) were not significantly associated with residents` level of knowledge regarding obesity and its management. (Table 3)

Majority of the participants (70.7%) agreed that adults with normal BMI should be advised by his GP to maintain his weight. Almost two-thirds of them agreed that the minimal weight loss can lead to important medical benefit (65.6%) whereas 67.3% disagreed that adults with BMI above 25 kg/m² should be offered treatment (drug) for weight loss and 67.2% disagreed that they would only offer advice regarding weight control when a patient request it. (Table 4)

Overall, more than half of the family Medicine residents (54.3%) expressed positive attitude towards obesity management as clear from Figure 3.

It is evident from Table 5 that the positive attitude towards obesity management increased steadily with increase in the residency level; being lowest in PGY1 (42.9%) and highest in PGY4 (75%), p=0.016. Similarly, it increased significantly with increase in the years of experience, being 45% among those with less than one year of experience and 100% among those with 5 years or greater of experience, p=0.011. Other studied factors (gender, age, body mass index and history of attending course or workshop about obesity and its management) were not significantly associated with residents` level of attitude towards obesity management. (Table 5).

Majority of the physicians were always offering weight control advice for their patients with chronic illness as part of the management (83.6%), using BMI to diagnose overweight or obesity (81%), and advising their patients to increase physical activities to reduce their weight (71.6%). On the other hand, majority of them never have “a group support” for obese patients in their practice (78.5%), use "Waist hip ratio" to diagnose overweight or obesity (75%), or use "Weight without height" to diagnose overweight or obesity (66.4%).

Overall, adequate practice regarding obesity management was observed among 61.2% of the family medicine residents as clear from Figure 4.

All obese class II resident physicians and 80% of those of class I compared to only 33.3% of underweight and 55.1% of normal subjects had adequate practice regarding obesity management, p=0.008. Other studied factors (gender, age, training level, experience and history of attending course or workshop about obesity and its management) were not significantly associated with practice of the physicians regarding obesity management. (Table 7).

It is realized from Figure 5 that the commonest barriers faced by Family Medicine residents when managing patients with obesity were lack of training in obesity management (47.4%), lack of knowledge (45.7%), lack of effective referral system (39.7%) and lack of time (38.8%).

4. Discussion

As it is important to improve competency and management skills of Family Medicine training program candidates, as they will be the first line of defense against the prevalent obesity problem in the Kingdom of Saudi Arabia ¹¹, the present study was carried out to assess the knowledge, attitudes, and practices of the joint program of family medicine candidates in Makkah regarding obesity management.

In the present study, excellent knowledge were reported regarding the ideal components of the weight management program, the fact that BMI is the most commonly used diagnostic tool for obesity, the most important risk factors for obesity, the fact that Orlistat is considered the anti-obesity drug of choice, definition of sever or morbid obesity, and the fact that BMI>35 kg/m² with co-morbidities is an indication for bariatric surgery. However, insufficient knowledge was reported regarding the facts that 5-10 kg in one year is the target of weight loss to get health benefits and Propranolol and Clozapine medications may induce obesity. The overall level of knowledge regarding obesity and its management was good among 57.8% of the resident physicians. In Aseer Region ⁵, 64% of primary healthcare physicians showed inadequate knowledge regarding obesity and it`s management. This is expected as resident physicians are newly graduated with updating knowledge compared to primary healthcare physicians.

In the current survey, residency level was significantly associated with knowledge about obesity and its management as the highest rate of good knowledge was observed among postgraduate year 2, then 3, and 4 whereas the lowest level was reported among those of postgraduate year 1. This could be explained by in the postgraduate year 1, the residents are building knowledge about obesity management during their hospital rotations, and they are using that knowledge in the following years of training.

The current study revealed that the majority of the participants agreed that adults with normal BMI should be advised by their physicians to maintain their weight and the minimal weight loss can lead to important medical benefit. Majority of the physicians in the present survey disagreed that adults with BMI above 25 kg/m² should be offered medical treatment for weight loss and they would only offer advice regarding weight control when a patient request it. In another Saudi study ⁶, a large proportion of the primary healthcare physicians held strongly positive attitude regarding their role in obesity management as reflected by their commitment to advice on weight loss even if not asked for by their patients, despite the feeling of difficulty to reach their goals. In studies carried out in New South Wales ⁷ and France ⁸, half or more of general practitioners (GPs) believed that weight reduction is difficult for the majority of people. It has been proved that personal desire to lose weight correlates positively with success of weight reduction programs among obese/overweight patients ¹². Also, in New South Wales ⁷, most of the GPs believed that it is their role to manage overweight and obesity, and they feel confident to manage adult with obesity.

Overall, positive attitude towards obesity management was expressed by almost half of the physicians in the present study. In another Saudi study ⁵ carried out in Aseer Region, majority of primary healthcare physicians showed a good attitude regarding obesity management. Also, in Eastern Saudi Arabia ⁶, majority of primary healthcare physicians believed that they should play an important role in obesity management. Difference in the nature of the target population could explain the difference between the present study and those of Aseer and Eastern regions. In France, majority of GPs have a high belief that obesity is a serious medical issue and considering it as a disease ⁸.

In the current study, positive attitude towards obesity management increased steadily with increase in the residency level. It also increased significantly with increase in the years of experience. This is quite expected as their experience with patients increased.

The current study revealed that majority resident physicians always offered weight control advice for their patients with chronic illness as part of the management, used BMI to diagnose overweight or obesity and advised their patients to increase physical activities to reduce their weight. On the other hand, majority of the physicians in the present study never had “a group support” for obese patients in their practice, never use "Waist hip ratio" or use "Weight without height" to diagnose overweight or obesity. In Aseer Region ⁵, more than half of primary healthcare physicians gave advice about the roles of diet, and exercise in the management of obesity. In Eastern Saudi Arabia ⁽⁶⁾, majority of primary healthcare physicians provided advices about dietary habits, and physical activities to their obese patients, and one-third of them believed that they are well competent for the management of obesity. In France ⁸, 42% of GPs considered themselves well prepared to manage obesity.

Overall, adequate practice regarding obesity management was observed among 61.2% of the family medicine residents in the present survey. Interestingly, in the present study, obese resident physicians had more adequate practice regarding obesity management compared to normal and underweight subjects. This is could be explained by more feeling of the problem by obese physicians as they are suffering burden of the problem.

Although the present study revealed that almost half of the family medicine residents had attended course or workshop about obesity and its management, this was not associated with improved knowledge, attitude and practice of obesity management. This raised a concern regarding the quality and contents of such educational activities. However, in another study carried out in New South Wales ⁷, GPs who attended courses and workshops about obesity and overweight were more confident to deal with such cases.

In the current study, the commonest barriers faced by Family Medicine residents when managing patients with obesity were lack of training in obesity management, lack of knowledge, lack of effective referral system and lack of time. In a study carried out by Al-Khaldi et al in Aseer region ⁵, the most common barriers to provide good management for obesity among primary healthcare physicians were lack of: time, lack of health education materials, lack of guideline, and lack of effective referral system.

Conduction of the study among Family Medicine residents in Makkah Region limited the generalizability of its results over resident physicians in KSA or even the primary care physicians in Makkah. Also, the cross-sectional design adopted in this study is considered another limitation as it doesn`t prove causality. Despite of that, the study carries out a great importance in exploring this important issue in our country with increasing in the burden of obesity problem and its adverse consequences.

5. Conclusion

Good Knowledge, positive attitude and adequate practice of the family medicine residents in Makkah city regarding obesity and its management, with some deficient points in knowledge, some negative points in attitude and some defective issues in practice. Their residency level impacted the knowledge and attitude levels. Their experience affected their attitude positively. Obese residents expressed better practice than others. Attending courses or workshops about obesity and its management did not influence residents` knowledge, attitude and practice of obesity management. The commonest barriers faced by Family Medicine residents when managing patients with obesity were lack of training in obesity management, lack of knowledge, lack of effective referral system and lack of time.

6. Recommendations

Ÿ More training and continuous medical educational activities are needed for family medicine residents in obesity management to improve their knowledge attitude and, skills. This could be achieved by conduction more high-quality lectures and workshops, with implanting a short clinical rotation in obesity clinics.

Ÿ Provision of an effective referral system from PHCCs to hospitals and increase the awareness of the residents about it is highly needed.

Ÿ Increase the time that is allowed to the Patient with obesity by implanting specialized obesity clinic in every PHCCs, which could be operated by resident qualified with a good training in obesity management.

Ÿ Primary healthcare physicians, including residents should be encouraged to work collaboratively with dietitians in managing patients with obesity, after insuring the availability of the dilatation in every PHCCs.

Ÿ Further study including residents from other areas in the kingdom and also other primary care professionals is recommended to have more clear view.

References