Perception among doctors of Pakistan about using Bariatric Surgery in Morbidly Obese Patients

doi:10.21203/rs.3.rs-5200201/v1

Introduction:

Obesity is a global epidemic, with Pakistan being the ninth most obese country, affecting one in four individuals. Literature suggests that less than 1% of eligible patients opt for bariatric surgery, indicating its underutilization. This is due to physicians' limited understanding of its effectiveness, which affects referral rates. This study aims to evaluate doctors' perceptions of bariatric surgery, including its benefits and complications.

Methods

This multicenter cross-sectional study, conducted from January to September 2024, included doctors of varying training levels and specialties. Data were collected using non-probability convenience sampling and analysed with STATA 17. P-value <0.05 was considered significant.

Results

Our study involved 414 doctors, mostly females (63.5%), aged 26-35 years (89.3%), with 0-5 years of experience (76.3%) and primarily from surgical and allied fields (44.4%). Nearly all respondents (96.8%) were aware of bariatric surgery as an effective weight loss tool, views on its safety varied, with 46.86% considering it safe and 21.98% viewing it as cosmetic. Complications were estimated by 41.06% to be 5-10%, and 40.1% thought they could be fatal. About 26.57% lacked confidence in discussing bariatric options, with gender-based differences (p=0.019). Most participants (90.82%), primarily from surgical and allied fields, felt more educational resources were needed, with differences across specialties (p=0.005).

Conclusion

In conclusion, although doctors acknowledge the effectiveness of bariatric surgery, concerns about safety and complications lead to reluctance in recommending it. Targeted education is essential for doctors to confidently counsel patients about bariatric surgery.

Obesity

Bariatric surgery

doctors perception

weight loss surgery management of obesity

body mass index

1. This study reflects awareness regarding bariatric surgery among doctors of Pakistan.

2. All doctors acknowledge the effectiveness of bariatric surgery as an effective weight loss method.

3. Doctors are skeptical about safety margins and post-op complications of Bariatric Surgery.

4. Doctors are not confident enough in explaining bariatric options to patients and express the need for additional education resources in this field.

According to the World Health Organization, obesity has been classified as a global epidemic, posing substantial challenges to public health systems worldwide (1, 2). Currently, Pakistan ranks as the ninth most obese country in the world, with approximately 25% of its population diagnosed as clinically obese (3).

Individuals with obesity have an increased risk of facing various non-communicable diseases, such as cardiovascular disease, hyperlipidemia, hypertension, asthma, obstructive sleep apnea, gastrointestinal problems, type 2 diabetes, joint conditions, and psychological challenges that not only impact their everyday life but also increase their mortality risk (4, 5).

Numerous approaches for weight loss, ranging from diet, exercise, behavioral therapy, and medication have been used to address obesity. However, non-surgical approaches are only effective in 3–9% of cases, with patients typically losing 5–10% of their initial weight but often fall short in maintaining substantial weight loss (6, 7).

Bariatric surgery (BS) has emerged as the most impactful intervention for promoting weight loss in obese individuals (5). The supporting evidence largely comes from relatively short-term follow-ups, spanning 1 to 3 years, in randomized clinical trials. These trials indicate that bariatric procedures outperform nonsurgical interventions and lead to significant improvement in health issues. Notably, it is regarded as a more enduring solution, providing long-term weight management benefits and improvements in associated comorbidities (8, 9).

The American Society for Metabolic and Bariatric Surgery found that less than 1% of eligible obese patients opt for BS (5). Literature suggests that patients are more likely to opt for BS if recommended by their doctor. Doctors' recommendations outweigh factors like patient demographics or other health issues related to obesity (10). Research indicates that doctors often lack sufficient knowledge about BS, remaining unaware of its benefits in managing obesity. They also harbor doubts regarding the procedure's safety and potential complications. There is a scarcity of research in Pakistan addressing physicians' perceptions about BS.

The objective of our study was to assess doctors' familiarity with BS for managing obesity. Additionally, our study seeks to assess their proficiency in explaining these procedures to patients and determine if there is any need for supplementary materials. We also investigated the frequency of doctors knowledgeable about the benefits and complications associated with these surgical procedures.

Study Design, Participants and Duration

This multicenter cross-sectional study was conducted from January 2024 to September 2024 after taking approval from an ethical review committee (reference number 1017-2024- LNH-ERC). A non-probability convenient sampling technique was employed in this study. The participants consisted of doctors at various levels of training, including interns, medical officers, residents, senior registrars, and consultants across diverse medical specialties. These specialties were broadly classified into four major groups: medicine and allied (which included cardiology, endocrinology, critical care, oncology, psychiatry, radiology, pediatrics, and family medicine), surgical and allied fields (encompassing orthopedic, urology, ENT, gynecology and obstetrics, anesthesiology, ophthalmology, emergency), non-clinical (consisting of doctors from hematology, histopathology, public health, and basic science faculty), and the last group, dentistry (including oral and maxillofacial surgery doctors). The inclusion criteria consisted of doctors who are in practice for at least past 6 months. The exclusion criteria consisted of doctors who are already practicing BS.

Data Collection Instrument, Procedure and Analysis

Data were collected through a self-administered online questionnaire using a Google Form link. Informed consent was sought from all participants with an assurance of complete confidentiality. The questionnaire consisted of two sections, Section (A) included Demographic characteristics, consisting of age, gender, field of specialty, years in practice, and specialty and Section (B) had questions related to perceptions and practices of doctors regarding BS. The questionnaire was sent to a panel of experts for content validity, which was followed by a pilot study from 25 doctors. After the complete survey, the information was entered and coded using MS Excel. Subsequent analysis was conducted utilizing STATA version 17. For descriptive statistics, frequencies and percentages were calculated. The associations between demographic variables and outcome variables were tested by the chi-square test. The significance level for all group comparisons was set at a p-value < 0.05.

In this study, 414 healthcare workers participated, predominantly females (63.5%), aged 26-35 years (89.3%), and having 0-5 years of practice (76.3%). The distribution of training levels included majorly medical officers (32.13%) and residents (31.16%). Various specialties were represented, with the majority (44.4%) in surgical and allied fields, followed by medicine and allied, non-clinical, and dentistry. Table 1 displays the study demographics.

Table 1: Frequencies and percentages of demographic characteristic

Category

Frequency (n)

Percentage (%)

Gender

Female

Male

263

151

63.5

36.4

Age Categories

26-35

36-45

46-55

56-65

370

33

6

5

89.3

7.97

1.45

1.21

Year of practice

0-5

6-10

11-15

16-20

>20

316

67

18

3

10

76.3

16.1

4.35

0.72

2.42

Level of training

Intern

Medical Officer

Resident

Senior registrar

Consultant

84

133

129

38

30

20.29

32.13

31.16

9.18

7.25

Specialty

Intern

Medicine and Allied

Surgery and Allied

Non-Clinical

Dentistry

62

149

184

16

3

14.98

35.99

44.44

3.86

0.72

Most of the doctors; 95.17% acknowledged obesity as a disease. Virtually all respondents (99.28%) believed that untreated obesity could lead to significant medical issues such as hypertension and diabetes mellitus and almost three-quarters of them (76.57%) expressed confidence in the capacity of weight loss surgeries in improving obesity-related complications. Nearly half (49%) perceived a very high risk of health issues if obesity was not managed timely (Figure 1).

Figure 1: Perceptions of participants regarding getting health problems if obesity not treated

Table 2 shows a high level of awareness about BS was observed among respondents, with 96.8% having heard about it. Additionally, 97.8% knew that surgical methods could reduce weight, and 85% believed it was a valuable tool for extreme obesity (Figure 2). However, almost 21.98% also classified BS as a cosmetic procedure instead.

Table 2: Knowledge of participants regarding BS

Questions

Frequency (n)

Percentage (%)

Awareness about BS

Yes

No

401

13

96.86

3.14

Aware that surgical methods can reduce weight

Yes

No

Do not know

405

4

5

97.83

0.97

1.21

Figure 2: Perceptions of participants regarding BS as a valuable tool for extreme obesity

Concerns about the safety of BS were evident, as 46.86% considered it safe, 35.02% were unsure, and 14.49% did not believe it was safe. Reported complications were perceived to be between 5-10% by 41.06% of participants, and 40.1% believed these complications could lead to death, though most classified the likelihood of death as low.

In terms of communication, 64.25% felt comfortable discussing BS options with patients, while 26.57% were unsure. A substantial majority (90.82%), primarily from the field of surgery and allied fields, expressed the need for additional medical resources in this context.

Doctors at different levels of training showed varying perceptions of complications leading to death after BS (p=0.022) (Supplementary Table 1). Variability in perception was also observed among different specialties, with surgeons showing a significant difference (p=0.004) (Supplementary Table 2).

Physicians and surgeons from diverse training levels had differing views on classifying BS as a cosmetic procedure (p=0.004) (Supplementary Table 1). A statistically significant difference (p=0.019) was found between male and female doctors in their comfort level when explaining BS options to patients (Table 3). A significant difference was also seen in male and female doctors' perception about complications of weight loss surgeries (p=0.036) (Table 3). Doctors from various specialties reported a significant difference in their perceived need for educational resources on BS (p=0.005). (Supplementary Table 2).

Table 3: Frequencies and percentages of perceptions based on gender

Questions

Total n(%)

Male n(%)

Female n(%)

p-value

Believes obesity is a disease

Yes

No

394 (95.17)

20 (4.83)

145 (96)

6 (4)

249 (94)

14 (6)

0.538

Classifies BS as a cosmetic procedure

Yes

No

Maybe

91 (21.98)

205 (49.52)

118 (28.5)

40 (26.4)

66 (43.7)

45 (29.8)

51 (0.19)

139 (52.8)

73 (27.7)

0.138

Thinks being obese or overweight can cause significant medical problems

Yes

No

Maybe

Do not know

411 (99.28)

1 (0.24)

149 (98.6)

0 (0)

1 (0.6)

262 (99.6)

1 (0.3)

0 (0)

0.254

Believes that weight loss surgeries can improve obesity related complications

Yes

No

Do not know

Not Sure

317 (76.57)

15 (3.62)

4 (0.97)

78 (18.84)

121 (80.1)

7 (0.04)

0 (0)

3 (1.98)

196 (74.52)

8 (3.04)

4 (1.52)

55 (20.91)

0.171

Thinks weight-loss surgeries are safe procedures

Yes

No

Do not know

Not Sure

194 (46.86)

60 (14.49)

15 (3.62)

145 (35.02)

76 (50.33)

25 (16.55)

6 (3.97)

44 (29.13)

118 (44.8)

35 (13.30)

9 (3.42)

101 (38.4)

0.291

Perceived complication of weight loss surgeries in percentage

Less than 1%

Less than 5 %

5-10%

10-30%

40-50%

More than 50%

10 (2.42)

98 (23.67)

170 (41.06)

111 (26.81)

22 (5.31)

3 (0.72)

4 (2.6)

39 (25.8)

72 (47.6)

33 (21.8)

3 (1.9)

0 (0)

6 (2.2)

59 (22.4)

98 (37.2)

78 (29.6)

19 (7.2)

3 (1.1)

0.036*

Think that the surgeries for obesity and their complication may lead to death

Yes

No

Do not know

166 (40.1)

113 (27.29)

135 (32.61)

61 (40.39)

46 (30.4)

44 (29.1)

105 (39.9)

67 (25.47)

91 (34.60)

0.415

Perceived likelihood of death after these procedures

Low

Moderate

High

305 (73.67)

103 (24.88)

6 (1.45)

118 (78.1)

32 (21.1)

1 (0.6)

187 (71.1)

71 (26.9)

5 (1.90)

0.228

Feels comfortable explaining the BS options to your patient when required

Yes

No

266 (64.25)

148 (35.75)

43 (28.4)

108 (71.5)

105 (39.9)

158 (60.0)

0.019*

Thinks continuing medical education resources in bariatric surgical would be useful

Yes

No

Maybe

376 (90.82)

12 (2.9)

26 (6.28)

137 (90.7)

5 (3.31)

9 (5.96)

239 (90.87)

7 (2.66)

17 (6.46)

0.915

*Significant difference calculated by chi-square test.

Majority of the doctors (96.8%) knew about the term BS. 85% believed it was a valuable tool for managing obesity.

A 2023 study conducted in Peshawar highlighted that only 47% of the practicing doctors believed in the untapped potentials of BS (10). Our study demonstrated a higher number of respondents, 85% considering BS as an implementable tool for morbidly obese patients. The former study reported a majority, 52.6% being either oblivious or dubious regarding the safety of BS whilst only few, 13.2% of their participants lacked confidence in their capability to counsel an obese patient regarding the necessary information about bariatric procedures (10). Similarly, our study yielded comparable results, with approximately half, i.e. 49.51% of our participants being unsure about the safety. However, similar to the Peshawar study, a larger percentage of respondents (64.25%) expressed confidence in their knowledge bank, equipped with the methods and measures necessary to minimize complications and ensure the sustained effectiveness of BS as a commendable treatment option. The pertaining doubts about safety of BS shows that doctors are still unfamiliar with details about advanced procedures compared to the west, who are better equipped than us to deal with the epidemic of obesity, due to higher prevalence in their region than the subcontinent (11).

Our study found that 41.06% of doctors perceived BS complications to be between 5–10% and 40.1% believed these complications could lead to death. A significant association was found in different levels of training and different specialties in their perceptions of complications leading to death after BS. Some of the complications observed by Chang et al including anastomotic leak, myocardial infarction and pulmonary embolism with rates documented to be as low as 1.15%, 0.37% and 1.17%, respectively (12), however there were no reported complications that could lead to death. Knowing that complication rate after BS is low (0 to 1.55%) and even lesser fatality rate (0 to 0.64%) (12), it is important to update our doctors with current facts, which could help them counsel their patients better, making them understand that BS boasts a notably low complication rate.

Our study results showed that the majority of doctors, 99.28% believed that untreated obesity could lead to significant medical issues and nearly three quarters believed that weight loss surgery can improve complications. A systematic review published in 2022 stated that only 1% obese individuals opted for bariatric procedures (13). Participants were observed to be more concerned regarding the cost of surgery, not realizing that untreated obesity can elevate the risk of related comorbidities, potentially leading to a higher financial burden and increased reliance on healthcare resources in the future (13).

Research suggests that many view traditional weight loss methods, such as portion control, exercise, and lifestyle changes, as more effective and superior to supposedly artificial means like surgery. Alshammari et al observed that 38% of physicians viewed BS as a favorable modality for weight loss, but more were aware about complications (64.8%) instead of their indications. (59.0%) (14). While it may be viewed as an aesthetic surgery, recent studies that consider BS as a medical necessity for patients with morbid obesity rather than a cosmetic procedure (15). Therefore Healthcare provider’s knowledge is crucial as they can rightly refer the patient when required to help improve their quality of life (16).

Previous literature primarily studied the perception of primary care physicians only (17). In contrast the current study encompasses practitioners from various levels of training. This is of significance as junior doctors have more day-to-day interaction with patients and their attendants (17) hence aiding them in making thoughtful decisions and clear misconceptions regarding BS. This compels regulatory bodies in the clinical side to impart sufficient knowledge about BS doctors at all levels of training aiming to normalize the stigma and myths surrounding BS (18).

Based on a 2022 survey conducted in community-based academic hospitals in the United States, it was found that 59.5% of physicians were at ease participating in the care of bariatric patients (17). Similarly, our study illustrates that 64.25% felt comfortable discussing BS options with their patients.

This study has few limitations, it may be subject to social desirability bias, also the study design is cross sectional and as the participants were mainly from a single urban city therefore, these findings may not be generalizable to doctors all over Pakistan.

Most doctors recognize the effectiveness of BS but concerns about safety and complications persist. Additional resources and research to enhance health care provider’s knowledge and counseling techniques are recommended.

DISCLOSURE

Authors declare no conflict of interest.

No funding was received for conducting this research.

Author Contribution

All authors have contributed equally to the research.

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No competing interests reported.

Supplementaryversion4.0.docx

Perception among doctors of Pakistan about using Bariatric Surgery in Morbidly Obese Patients

Status:

Version 1

Abstract

Figures

Key Points

INTRODUCTION

MATERIAL AND METHODS

Study Design, Participants and Duration

Data Collection Instrument, Procedure and Analysis

RESULTS

DISCUSSION

CONCLUSION

Declarations

Author Contribution

References

Additional Declarations

Supplementary Files

Status:

Version 1