Attitude and Belief of Healthcare Professionals Towards Effective Obesity Care and Perception of Barriers; An Updated Systematic Review and Meta-analysis

Background: Obesity is a serious chronic disease that adversely affects health and quality of life. However, a significant percentage of people do not participate in or adhere to weight loss programs. Therefore, a multidisciplinary approach is needed to identify critical barriers to effective obesity management and to examine health practitioners’ attitudes and behaviors towards effective obesity treatment. Methods: This systematic review was conducted in accordance with PRISMA 2020. Eligible studies were identified through a systematic review of the literature using Medline, Scopus, Cochrane, Google Scholar, Web of Science, and Embase databases from January 1, 2011 to March 2, 2021. Results: A total of 57 articles were included. Data on 12663 physicians were extracted from a total of 35 quantitative articles. Some of the most commonly perceived attitude issues included "obesity has a huge impact on overall health", "obesity is a disease" and "HCPs are to blame". Health professionals were more inclined to believe in "using BMI to assess obesity," "advice to increase physical activity," and "diet/calorie reduction advice." The major obstacles to optimal treatment of obesity were "lack of motivation", "lack of time" and "lack of success". Conclusion: Although the majority of health care professionals consider obesity as a serious disease which has a large impact on overall health, counseling for lifestyle modification, pharmacologic or surgical intervention occur in almost half of the visits. Increasing the length of physician visits as well as tailoring appropriate training programs could improve health care for obesity.


Introduction
Obesity is a chronic and important disease with increasing prevalence.In 2016, more than 1.9 billion people over the age of 18 were overweight, of whom 650 million were obese.3][4][5] Much more attention must be paid to the critical role of medical staff in achieving optimal outcomes in managing obesity, despite well-known obstacles such as poor patient motivation, non-adherence to treatment, and short appointment times. 6revious studies have shown that health professionals, including family physicians and general practitioners, lack sufficient understanding and competence regarding obesity, which is a barrier to effective obesity care. 7Since there are insufficient and inconsistent limited reviews, we performed this systematic review in order to explore the attitude and behavior of health-care professionals and perception of barriers towards effective obesity care.
with Preferred Reporting Items and checklist for Systematic Reviews and Meta-Analyses (PRISMA) 2020 (Figure 1) registered in PROSPERO (registration number: CRD42020148596) and was approved by Ethical committee of Iran University of Medical Sciences.(Ethical code: IR.IUMS.REC.1399.315) We searched Medline, Embase, Scopus, Cochrane Library, and Web of Science databases from January 1, 2011 to March 2, 2021 to identify relevant reports.Gray literature, including Google Scholar, was also explored.The search terms selected according to Medical Subject Heading (MESH) terminology included: "Obesity", "overweight", "belief", "barrier", "attitude", "behavior", "behavior", "Physician", "General Practitioner", "health care provider", "health care worker" using AND/OR in title and abstract.
A preliminary database search using the Endnote program identified 8319 articles, including two articles identified through the gray literature sources (Google Scholar).After removing duplicates, 4973 records remained and were reviewed by two investigators.Of these, 4879 articles were excluded through title and abstract verification.The remaining 94 full-text articles were evaluated using the following inclusion criteria: • Articles on adult obesity (excluding pediatrics) • English-language articles • Observational studies including case-control studies, cross-sectional studies and cohort studies • Articles available in full text • Articles which directly assess attitudes, beliefs and barriers to obesity care • Articles addressing medical professionals including doctors (excluding articles about patients).The reasons for excluding 37 records were: non-English language (n = 6), study type (n = 8), full text unavailable (n = 13), non-physician participants (n = 4), articles not relevant to aims of study (n = 6).Finally, we performed quality assessment of the remaining 57 articles using the JBI Critical Assessment Checklist for Cross-sectional Analysis Studies and scored on a 7-point scale.

Statistical Analysis
The DerSimonian-Liard random-effects model was used to estimate the pooled prevalence using the Metaprop command in Stata 16.Cochrane Q and I 2 tests were used to evaluate the heterogeneity and variance between studies.We used the funnel chart and its graph to assess publication bias.All two-step statistical tests were considered at α = 0.05.

Results
A total of 57 articles were included between 2011 and 2020.Of these, 12 articles were on barrier perceptions, half of which (6 articles) provided quantitative statistical data and the rest identified barriers qualitatively.Thirtyone articles were on attitude, 22 of which focused on quantitative information, and the remaining nine articles addressed qualitative information.The remaining 14 articles were on beliefs, with half of them being quantitative, and the rest qualitative.Different data collection methods were used such as Personal interviews, Telephone contacts, and Responses to surveys.
A total of 35 quantitative articles were included (Table 1).The total number of participating physicians was 12 663.The largest study population was in the study of Steeves et al, 8 which included 2022 individuals, and the smallest study population was in the study of McHale et al, 9 which included 14 individuals.
Funnel plots to assess publication bias are reported in Supplementary file 1.
Funnel plots to assess publication bias are reported in the Supplementary File.All of the qualitative studies mentioned that "lack of clearly specified practical guidelines and treatment options" are the main barriers.In addition, "limited understanding about obesity care, knowledge and skills" was the second major barrier.

Belief and Attitude
Obesity-related beliefs and attitudes refer to conscious perceptions, interpretations, and thoughts or feelings of obesity that lead to understanding and learning.This may motivate HCPs to provide the highest quality care. 11he majority of physicians consider obesity as a disease; however, obesity is not just about increased BMI.It is associated with changes in anthropometrics, metabolic function, and gait parameters.Glauser et al reported that the majority of respondents used body mass index for obesity screening. 10Considering the limitations of BMI and the importance of central obesity, body fat distribution which is closely linked to metabolic complications should be taken into account. 8Waist circumference and waist-tohip ratio could reliably distinguish central obesity from lower body and general obesity. 42pproaches to assessing obesity are multifaceted.Approximately 50% of physicians documented obesity as a problem, with attending physicians documenting obesity more frequently than residents (64% vs. 43%).On the other hand, normal-weight physicians reported obesity more frequently than overweight physicians (58% vs. 41%).Furthermore, doctors may not recognize obesity as a serious problem unless the patient's BMI exceeds 35 kg/m².Educational programs for health professionals are therefore needed to detect obesity early and increase the ratio of documentation.This could be a first step towards improving obesity management. 11egarding the physicians' perceptions of obesity, most HCPs and general practitioners (GPs) view obesity as a chronic disease.][13] In addition, the majority of health care professionals accept their responsibility to improve the situation and reducing the prevalence of this chronic disease.Moreover, they believe that they need to maintain a healthy weight in order to serve as a role model for their patients. 14,15owever, a study by Tiexeira et al showed that although GPs believe that counseling obese patients about health risks is part of their job, their perception about their role in treating obesity is negative.The majority of doctors believe that they make no difference in getting their patients to Barriers to effective obesity care make long-term lifestyle modification. 7Patient-centered communication, motivational interviewing, problemsolving, and action planning should be integrated into residency curricula and local continuing education programs.
Regarding interviews, Kirk et al showed that within the current healthcare system, HCPs are unable to provide the support obese people really need.They identified tensions within three themes expressed by groups of participants: "blame as a devastating relation of power, tensions in obesity management and prevention, and the prevailing medical management discourse". 43These are reflected tensions and varying discourses surrounding obesity, namely obesity as a personal issue, obesity as a social construction, and obesity as a complex health condition.The study by Heintze et al showed that while almost all of the HCPs felt responsible for providing obesity-related care, they felt they are incompetent. 44everal factors that are related to physician characteristics, such as physician BMI and specialty, may explain this issue.For example, normal-weight physicians reported more confidence in counseling patients compared to their overweight peers.Additionally, obese patients also reported more trust in receiving weight loss advice from normal-weight physicians. 44Similar beliefs can be applied to many specialists.Pediatricians and obstetricians felt limited impact on treatment efficacy compared to other disciplines, and this finding may be considered in continuing medical education programs.
One of the important issues about attitude toward obesity is patient awareness.Physicians believe that nearly half of patients neither have the necessary knowledge about obesity and its harms, nor the ability to lose weight.Hence, they will lose the battle.That is why the majority of HCPs and GPs believe that patient education improves this situation. 16,17On the other hand, about half of the HCPs and GPs mentioned the need for updating the existing guidelines. 10,17On the other hand, the perception of physicians about treatment modalities is quite diverse.While about 54% of participants believe that current guidelines are effective, 8,10,17,18 implementation of guidelines into daily practice is still far from the desired standards.
Only half of the participants (53%) follow treatment guidelines or provide educational materials. 14,19,20As a rule, the combination of dietary modification and exercise is the most effective behavioral modality for the treatment of obesity.In this regard, over 60% of physicians provide advice to their patient to improve physical activity [20][21][22][23] and make dietary modifications. 20,23,24Comparing different treatment modalities, many physicians expected larger weight loss with pharmacotherapy and surgery.The majority of primary care providers, endocrinologists, and cardiologists expected less weight loss with gastric bypass surgery while bariatric surgeons had a more reasonable expectation; a finding that could be explained by different educational and practical backgrounds. 8,10The study by Tsai et al revealed that physicians believe medication and surgery are less effective in comparison to lifestyle modification alone; thus, physicians who better understand the biology might be more open to using 'biologic' tools (medications and surgery).Perhaps, lack of valid and clear guidelines, as well as lack of proper awareness of the side effects and benefits of various interventions can play a role in this issue. 25Bleich et al confirm this fact that primary care physicians overwhelmingly supported additional training to improve nutrition and exercise counselling, optimal care related to bariatric surgery patients, as well as motivational interviewing. 45Primary care providers in this study also identified nutritionists/dietitians as the most qualified providers for obesity care.Barriers to effective obesity care

Barriers to Optimal Obesity Management Patient Factors Lack of Motivation for Weight Loss and Lack of Compliance for Maintaining Long-term Lifestyle Changes
Obesity should be considered and managed as a medical condition that is progressive, chronic, and relapsing. 46In this study, nearly 54% of physicians believed that patients with obesity are not motivated enough to lose weight.In addition, almost 50% of healthcare professionals believe that people with obesity are non-compliant with long-term lifestyle changes.In a study by Kim et al in 2020, about 80% of people with obesity had experienced at least one serious weight-loss effort in the past. 47nterestingly, only 12% of these people had successfully lost near 10% of their body weight, half of whom kept it off for at least one year. 47The relatively high failure rate can be partially attributed to lack of long-term adherence to the obesity treatment.Therefore, despite successful weight loss after bariatric surgery, weight regain may occur, especially if they are less motivated and fail to adhere to long-term lifestyle changes.Thus, as with other chronic diseases, patients with obesity require to understand that obesity is a serious, chronic, relapsing recurring disease, and maintaining adherence to lifelong lifestyle changes is crucial for the long-term weight loss maintenance.

Lack of Referral Options or Resources (Misbelief and Misinformation Around Obesity Treatment) and Lack of Training
People with obesity have different attitudes and beliefs about obesity and its management.8][49] According to this review, about 40% of healthcare professionals believe that patients with obesity would rather seek out medical advice themselves instead of visiting a licensed professional.

Stigma
Stigma is a common problem affecting the disabled community.Furthermore, it can lead to significant financial disadvantage; opportunities are denied and self-esteem is compromised.Many people with obesity feel that they are labelled as unmotivated, lazy, and uncooperative.According to this review, approximately 15% of health professionals reported having a negative attitude towards obesity.The negative attitude of health professionals towards obesity could be a potential barrier to optimal obesity care.Therefore, the medical profession should be more understanding, be compassionate with the patients and help them to lose weight.In addition, the negative attitudes of other members of the health care team and of course, the society towards the population with obesity need to be improved. 50

Physician Factors Lack of Time During General Practice Appointments
2][53][54] Therefore, most physicians do not consistently address the issue of overweight or obesity directly with their patients. 26,52,55According to this review, about 46% of healthcare professionals indicated that they do not talk about weight management with their patients because they do not have enough time in their appointments.

HCPs Misdiagnosis and Lack of a Formal Diagnosis of Obesity
Sometimes, it is difficult for healthcare professionals to diagnose obesity by means of visual inspection alone and therefore, obesity may not be addressed during a patient care visit.According to this review, the accuracy of visual assessment of BMI was 45%.As a result, in order to appropriately diagnose and manage obesity, the BMI of a patient must be consistently calculated by all practitioners. 27,56,57

Lack of Training and Obesity Counseling Competence (Lack of Expertise)
Although diet, nutrition, exercise, behavior therapy, and medication are among topics covered in obesity education for healthcare professionals, about 40% cited that they encounter various challenges to aligning their clinical practice with current obesity management guidelines.This leads to the conclusion that most medical school curricula do not encompass sufficient obesity education and thus, medical schools must adequately address obesity education in their curricula, including adequate nutrition and obesity medication education. 47,58,59re Important Concern to Discuss Discussions about the possible impacts of obesity on general health are a potentially disturbing and humiliating topic. 51In this study, almost 38% of the clinicians believed that there are more important clinical issues to discuss during their appointment rather than weight management.The majority of healthcare professionals (62%) indicated that they are very willing to discuss weight control issues with patients, but report that there are obstacles to starting these conversations.

Lack of Physician's Confidence
Physicians often report a lack of confidence in managing obesity.Among healthcare providers, physicians with a normal BMI are more confident in their capacity to provide patients with obesity diet, exercise, and counseling. 45bout 22% of the physicians in this review expressed lack of confidence in their ability to manage obesity.

Conclusion
Evaluation of attitudes, beliefs and barriers toward effective obesity care revealed that although most of the physicians consider obesity as a serious disease which has a large impact on health, counseling for lifestyle modification, pharmacologic or surgical intervention occur in almost half of the visits.Therefore, tailoring appropriate training programs is needed in order to improve the attitude and perception of health care professionals about optimal obesity care.

Figure 1 .
Figure 1.PRISMA 2020 Flow Diagram for Systematic Reviews with Database and Register Searches Only

Figure 2 .
Figure 2. The Pooled Prevalence of Attitude Scales in Healthcare Professionals Towards Effective Obesity Care (A: Medical guidelines is effective, B: HCPs have responsibility, C: Obesity is a disease, and D: HCPs management will success and feel confident)

Figure 3 .
Figure 3.The Pooled Prevalence of Belief Scales in Healthcare Professionals Towards Effective Obesity Care (A: Assess obesity and document it, B: Use BMI to assess obesity, C: counselling for eating habits/reducing calories, and D: counselling for increasing physical activity)

Table 1 .
Main Characteristics of the Included Studies

Table 2 .
The Quantitative Results and Pooled Prevalence of Scales Based on Meta-analysis Results