Overweight and obesity have become a global problem.^1,2 In 2010, it was estimated that overweight and obesity caused 3.4 million deaths and a loss of 3.9% of years of life globally.³ It has been suggested that unabated overweight and obesity could lead to a global decline in life expectancy in the United States⁴ as a result of the associated risk factors and comorbidities, such as cardiovascular disease (CVD), diabetes (type 2) and various cancers.⁵ 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 2025.⁶

In keeping with the global trend, in recent years there has also been a rise in the prevalence of overweight and obesity in the African continent.^7,8 South Africa has been reported to have the highest prevalence of overweight and obesity in Sub-Saharan Africa (SSA),⁹ which has been ascribed to socio-cultural, socio-economic and behavioural factors.¹⁰ In the late eighties, obesity was defined as ‘a condition of abnormal or excessive fat accumulation in adipose tissue, to the extent that health may be impaired’.¹¹

Parameters commonly used to measure overweight and obesity are the body mass index (BMI), waist circumference (WC) and waist–hip ratio (WHR).¹² The BMI (defined as the individual’s weight in kilograms, divided by the square of the height in metres (kg/m²)¹¹ provides the most useful population-level measure of overweight and obesity, but it is a crude index as it does not account for the wide variation in body fat distribution.¹³ The BMI is classified as follows: underweight (<18.5 kg/m²), normal range (18.5–24.9 kg/m²), overweight (25.0–29.9 kg/m²), obese class I (30.0–34.9 kg/m²), obese class II (35.0–39.9 kg/m²) and obese class III (≥40.0 kg/m²).¹¹

WC is a highly sensitive and specific measure of abdominal fat distribution and thus it is valuable for identifying overweight and obesity among patients at risk of developing metabolic complications. It is unrelated to height and correlates closely with BMI and WHR.¹¹ The cut-off points are WC > 102 cm for men and >88 cm for women.¹⁴ WC has been proposed to be the best indicator in the measurement of central obesity, with excellent correlation with abdominal imaging and high association with CVD risk factors, especially diabetes.^15,16 The WHR is also a measure of central obesity, since as the abdominal fat increases, so does the WC – relative to the hip girth.¹⁷ The cut-off points for defining central obesity are WHR > 1.0 in men and > 0.85 in women.^11,13

The graded classification of overweight and obesity is valuable as it allows meaningful comparisons of weight status within and between populations, identification of individuals and groups at increased risk of morbidity and mortality as well as the identification of priorities for intervention at individual and community levels.¹¹ In this study, we decided to use the BMI in the assessment of knowledge, attitudes and skills of medical practitioners as it is the most widely used measurement of overweight and obesity in all age groups.¹⁶

It has been shown that health professionals are poorly prepared to address overweight and obesity as a result of poor training in behavioural change strategies and the lack of experience in working within inter-professional teams.¹⁸ The central role of the primary health care practitioners (general practitioners and practice nurses) has been acknowledged in the United Kingdom and Scotland, resulting in the formulation of guidelines on overweight/obesity prevention and management at primary care level.¹⁹ The advantage of this strategy is the population coverage and continuity of care and trust built over a number of encounters,²⁰ and the practical application of the primary care principle that every patient encounter should be regarded as an opportunity for health promotion.²¹ The Royal College of Physicians in the United Kingdom has issued a report on the training of general practitioners in weight management. The report has indicated that the training was minimal and poorly coordinated – ‘a reflection of lack of focus on obesity throughout medical training as a whole’.²²

It has been shown that health care practitioners’ practice in the management of patients with overweight and obesity is influenced by their attitudes.¹⁹ In a study comparing weight bias in 2001 versus 2013 in the management of overweight and obesity among weight management specialists, it was demonstrated that there has been a paradigm shift from implicit (unconsciously expressed) to explicit (consciously expressed) anti-fat bias. The biases were expressed by the medical practitioners as bad, lazy, stupid and worthless.²³ The weight of the health care practitioner may also influence their attitudes towards management of overweight and obesity as an overweight and obese practitioner would be less inclined to advise on weight management. In addition, an overweight and obese patient may not take seriously advice from a practitioner of similar weight.¹⁹

Literature on the training of health care practitioners in general, and medical practitioners in particular, in Africa is lacking. Most of the studies report on nutrition and management of patients with overweight and obesity.^24,25 However, in South Africa, Malan, Mash and Everett-Murphy published work on development of a training programme to counsel patients on risky behaviour (including physical inactivity and unhealthy diet),²⁶ and evaluation of a training programme for primary care providers on brief behavioural change counselling (BBCC) on risk factors for non-communicable diseases which could result from overweight and obesity.²⁷

The aim of this study was to determine the knowledge, attitudes and management skills of medical practitioners in the management of overweight and obese patients at Odi District Hospital in the Gauteng Province. At the time of the study, the medical practitioners at the hospital comprised three categories: community service doctors, medical officers (MOs) and registrars (residents). In the South African health care system, a 2-year internship programme is followed by 1 year of community service, hence the title of community service doctor. The medical practitioner who has completed his/her community service year and is practicing in the public service is referred to as a MO. A registrar is a medical practitioner who is pursuing specialist training in a particular medical discipline; General Surgery, Family Medicine, and so on.²⁸ In this study, all the registrars were trainees in Family Medicine.

The Medunsa Research and Ethics Committee (MREC) approved the study and allocated the clearance certificate number MREC/M/27/2013:PG. The clinical manager at Odi Hospital gave permission to conduct the study at the site. All respondents provided written informed consent for the study. Participation was voluntary and the respondents were informed of their right to withdraw from the study at any stage without negative consequences. Anonymity and confidentiality of the collected data were also confirmed.

In Table 1, the baseline characteristics of the participants are documented and they show that the majority of the medical practitioners (21; 43%) were aged between 31 and 40 years. There were more male medical practitioners (28; 58.3%). Most of them (34; 70.8%) had graduated between the year 2001 and 2011. The MOs and registrars constituted the highest percentage (89.6%).

Table 2 shows that among the three community service doctors in the hospital, two (66.7%) had received training on the management of overweight and obesity (after qualifying as medical practitioners). The majority of the MOs (18; 85.7%) and registrars (17; 77.3%) responded that they had not received training in the management of overweight and obesity. In both cases, there was a significant difference between those who responded that they had received training versus those who reported to the contrary (p < 0.001). When all the medical practitioner categories were pooled together, there was a statistically significant difference between those who indicated that they had received training on overweight and obesity management (11; 22.9%) versus those who indicated that they had not (37; 77.1%), (p < 0.001).

Table 3 shows that 47 (97.9%) medical practitioners agreed with the statement that overweight and obesity was a problem in South Africa. Medical practitioners demonstrated poor knowledge on the classification of BMI (p < 0.05). Ten (20.8%) medical practitioners were unsure whether a sustained 10% body weight loss over 6 months was an important goal in the management of overweight and obesity.³³ Forty (83.3%) medical practitioners disagreed that overweight and obesity management was effective at Odi Hospital.

Table 4, which reflects medical practitioners’ attitudes, demonstrates that 32 (66.7%) medical practitioners disagreed that management of overweight and obesity was the responsibility of a dietician versus 10 (20.8%) who agreed, with a statistically significant difference between the two groups (p < 0.001). Forty-five (94.0%) medical practitioners disagreed with the statement that overweight and obesity management is the sole responsibility of a specialist in internal medicine. Thirty-seven (77.1%) medical practitioners disagreed that the undergraduate training on overweight and obesity management was adequate for them versus two (4.1%) who agreed (p < 0.001). Twenty-two (45.8%) medical practitioners agreed with the statement that overweight and obesity should be managed at the primary health care level versus 17 (35.4%) who disagreed (p = 0.298).

Medical practitioners did not differ significantly (p = 0.308) between those who were confident on the management of overweight and obesity among adult patients (21; 43.7%) versus those who were not (26; 54.2%). They differed significantly with regard to management of overweight and obesity among children (p < 0.001). There were more medical practitioners who agreed (22; 45.8%) that management of overweight and obesity was difficult for medical practitioners versus those who disagreed (17; 35.4%), but there was no statistically significant difference between the two groups. Twenty-seven (56.2%) medical practitioners agreed with the statement that overweight and obesity management was usually unsuccessful, while 13 (27.1%) disagreed (p = 0.004). The same results were obtained for the statement that medical practitioners lacked interest in the management of overweight and obesity.

The recording of patients’ weight as part of the management of patients with chronic diseases was done most of the time by 15 (31.3%) medical practitioners, while 28 (58.3%) indicated that they did so occasionally (p = 0.008). Twenty-nine (60.4%) medical practitioners indicated that they recorded patients’ weight as part of opportunity screening for overweight and obese patients versus 11 (22.9%) who did so occasionally (p < 0.001). Twenty-four (50%) medical practitioners indicated that they measured the weight of overweight and obese patients routinely versus 17 (35%) who did so occasionally – but there was no statistical difference between the two groups (p = 0.150).

Provision of lifestyle modifications as part of the management of patients with overweight and obesity was done most of the time by 47 (97.9%) medical practitioners versus 1 (2.1%) who did so occasionally (p < 0.001). Involvement of the patient’s family members in the management of the patient’s overweight and obesity was done most of the time by 43 (89.6%) medical practitioners, while 3 (6.3%) did so occasionally (p < 0.001) (Table 5).

Table 6 shows that there were significantly more non-registrars 11 (52.4%) versus registrars 4 (20.0%) who indicated that they recorded weight as part of management of patients with chronic diseases (p = 0.033). There were also significantly more non-registrars 14 (77.8%) versus registrars 8 (38.1%) who measure weight for overweight patients routinely (p = 0.013). There were no other significant differences in knowledge, attitudes and practice relating to the management of overweight and obesity between registrars and non-registrars (p > 0.050).

This study has shown that there was a significantly fewer number of medical practitioners who had received training in weight management. A high percentage (97.9%) of the medical practitioners were aware that overweight and obesity are a problem in South Africa, but >60% of them did not know the classification of overweight and obesity according to the BMI. Their attitudes were that weight management was not primarily the responsibility of a dietician or a specialist in internal medicine. However, they were not confident in the management of overweight and obesity in children. They regarded weight management as usually unsuccessful and regarded themselves as lacking interest in weight management. They occasionally (versus ‘most of the time’) practised BMI measurement but provided lifestyle modifications and involved the patient’s family in weight management most of the time. More non-registrars compared with registrars measured patients’ BMI as part of the management of patients with chronic diseases and as routine for overweight patients.

In our study, almost all the medical practitioners (97.9%) were aware that overweight and obesity was a problem in South Africa. Indeed, a study has shown that in South Africa, the prevalence of overweight and obesity increased significantly from 23.5% in 2008 to 27.2% in 2012 (p < 0.001).³⁴ More than 60% of the medical practitioners demonstrated good knowledge on the classification of BMI. This was higher than the percentage obtained by Block et al. in their survey of residents in internal medicine that revealed that only 40% displayed good knowledge about BMI.³⁵ In a study conducted in Hungary on the evaluation of the knowledge, practice and attitudes of medical practitioners, it was found that awareness of the diagnostic threshold for overweight and obesity in terms of the BMI was 51% among general practitioners (an equivalent of MOs in our study) and 90% among residents (an equivalent of registrars in our study).

In this study, two-thirds of the medical practitioners indicated that overweight and obesity management was not primarily the responsibility of a dietician, and about nine-in-ten disagreed that overweight/obesity management was solely the responsibility of a specialist in internal medicine. Indeed, the management of overweight and obesity has been found to have a wider objective than weight loss alone – it includes mortality risk reduction and improvement of the quality of life.³⁶ Therefore, appropriate management of overweight and obesity should be interdisciplinary, including lipid profile control, blood pressure management, evaluation of respiratory disorders (e.g. sleep apnoea syndrome), pain control for arthritis and management of psychosocial disturbances (e.g. eating disorders).³⁵

More than three-quarters of the medical practitioners disagreed that overweight and obesity management were adequately covered at undergraduate medical training. In its report referred to earlier in this article, The Royal College of Physicians has indicated that the minimal and poorly coordinated training of medical practitioners on weight management reflected lack of training on overweight and obesity at undergraduate level.²³

More medical practitioners (45.8%) expressed difficulty in managing overweight and obesity. This has been shown to be related mainly to three barriers in the initiation of the topic: lack of competence on overweight and obesity care, concern about possible negative consequences elicited by introducing the topic to patients during a consultation and time constraints and limited resources to raise the sensitive topic,³⁷ especially if the overweight and obesity are not the presenting complaint in a given consultation. Since Odi District Hospital is a primary health care facility with a large workload of patients, the authors are of the opinion that the medical practitioners had a similar explanation for the difficulty they expressed in the management of overweight and obesity.

Schmidt et al. in their study on how weight management specialists treated overweight and obesity before 2012 discovered that 99% of them used stimulant medication (amphetamines, diethylpropion and phendimetrazine) without time limit on amphetamines (50%) and at higher doses than recommended in the package insert.³⁸ In our study, we did not require the medical practitioners to provide us with the medication names. According to the knowledge of the authors, weight control medication is excluded from the medical formulary of the South African public sector health care facilities.³⁹ Therefore, at Odi District Hospital, each practitioner would refer patients in need mainly to the private sector facilities. The main emphasis on weight management in the public sector would be lifestyle modifications.²⁸

More than half of the medical practitioners (54.2%) indicated that they were not confident on the management of overweight and obesity among adult patients, in keeping with the study by Block et al. where medical practitioners expressed negative opinions about their skills for treating obese patients.³⁵ The percentage was significantly higher (72.9%) among medical practitioners who expressed lack of confidence in the management of childhood overweight and obesity. Several studies have indicated that overweight and obesity treatment could improve in primary care by supporting practitioners to identify and manage paediatric patients.^40,41,42

In this study, about half (56.2%) of the medical practitioners viewed management of overweight and obesity as usually unsuccessful, in keeping with a study by Ferrante et al. in their survey of practices and attitudes of family physicians in New Jersey (USA), where 51% of the family physicians regarded treatment for overweight and obesity as often ineffective.⁴³ Nevertheless, health care providers need to show interest in weight management as it has been demonstrated that patient behavioural change increases with provider encouragement and goal setting.⁴⁴

Significantly, more medical practitioners (58%) recorded patients’ BMI occasionally (versus 31% who indicated ‘most of the time’ as part of the management of patients with chronic diseases. Overweight and obesity should be included among the list of chronic diseases as it is a component of the metabolic syndrome, the other components being an increased WC, elevated triglycerides, reduced high-density lipoprotein (HDL) cholesterol, elevated blood pressure and elevated fasting glucose.⁴⁵ Successful overweight and obesity management, as chronic diseases, has been shown to improve the quality of life. This has been demonstrated in the study by Sarwer et al. conducted at the University of Pennsylvania (United States) where a mean weight loss of 3.9 ± 0.3 kg was associated with improvement in the quality of life.⁴⁵

Our study demonstrated that almost 98% of medical practitioners indicated that they provided lifestyle modifications as part of the management of patients with overweight and obesity. The effect of this intervention, albeit only verbal, should not be underestimated as it has been shown that advice on losing weight by a health care professional was associated with the desire and attempt to lose weight (OR = 3.71 and OR = 3.53, 95% CI, respectively) among overweight and obese British adults – independent of demographic and weight status.⁴⁶

Almost 90% of medical practitioners indicated that they involved the patient’s family members most of the time in the management of the patient’s overweight and obesity. It has been shown that social support from family and friends is effective in assisting patients to shed weight and prevent weight gain.^47,48

There were significantly more non-registrars (52.4%) versus registrars (20.0%) who indicated that they measured patients BMI as part of management of patients with chronic diseases, and also significantly more non-registrars (77,8%) who measured the BMI among overweight patients routinely. Weight loss in overweight and obese patients has been associated with improvement of chronic conditions such as asthma,⁴⁹ CVD (including heart failure),⁵⁰ and diabetes mellitus.⁵¹

Regarding BMI measurement, we would have expected an opposite finding in which registrars would have performed this measurement more than non-registrars, given that the former were undergoing post-graduate training in patient care. The explanation for this opposite finding is unclear to the authors. However, we are aware of the studies by Ferrante et al. in which they reported that family physicians expressed difficulty in conducting a physical examination (including weight management) in obese patients,⁴³ and Rurik et al. who reported inconsistency among family physicians in Hungary in measuring patients’ anthropomorphic indices.⁵²

The number of medical practitioners who had received training in weight management was significantly small. Almost all of the medical practitioners were aware of the problem of overweight and obesity in South Africa, but > 60% did not know the BMI classification of overweight and obesity. Their attitudes were that weight management was not mainly the responsibility of a dietician and not the sole responsibility of a specialist in internal medicine. Nevertheless, they were not confident in the management of overweight and obesity in children. They regarded weight management as usually unsuccessful and regarded themselves as lacking interest in weight management. They occasionally practiced BMI measurement but provided lifestyle modifications and involved the patient’s family in weight management most of the time. Non-registrars measured patients’ weight as part of the management of patients with chronic diseases and measured patients’ BMI routinely – significantly more than the registrars.