Exploratory study on the self-perceived knowledge and care competence of general practitioners in managing patients with overweight and obesity in Austria

Obesity is a complex, multifactorial chronic disease, influenced by numerous endogenous and exogenous factors [1, 2]. The prevalence of overweight and obesity is increasing worldwide. In Austria, the prevalence of obesity is expected to increase annually by 2.4% among adults and 2.8% among children, with more than one-third of the adult population projected to be obese by 2035 [3]. Given these high numbers, primary care providers increasingly encounter overweight and obese patients. However, obesity is often underdiagnosed and undertreated, with primary care facing multiple barriers to providing adequate care [4‐7].

In Austria, primary care is mainly delivered through solo practices, with 89% of contracted general practitioners (GPs) operating solo in 2018 [8]. The majority of primary care is provided by GPs with health insurance contracts, but there is a trend towards private practices [9, 10]. Regarding the treatment of chronic diseases, Austria has traditionally reported higher rates of potentially avoidable hospital admissions for chronic conditions compared to many European countries [10]. These rates have declined over the past decade and are now closer to the EU average. Despite this progress, Austria’s hospital-centered healthcare system continues to limit primary care’s ability to manage chronic diseases effectively. Efforts to strengthen primary care and reduce hospital admissions are ongoing, but structural and financial fragmentation remains challenging [10].

Currently, obesity treatment in primary care presents multiple challenges. Many guidelines highlight the importance of an interdisciplinary approach to care, but the structure of the primary care system limits access to these services [1, 11‐13]. There are various therapy programs, mainly offered by health insurance funds in Austria’s federal states (e.g., “Easy Kids”, “Leichter Leben”), which mainly focus on the aspects of nutrition and exercise, but also on behavior. However, there is no standardized concept for structured obesity care in Austria. International comparisons, such as Germany’s recent steps toward a structured obesity disease management program (DMP) [14], highlight Austria’s need for improving coordination and resources.

The aim of this study was to explore GPs’ experiences in managing overweight and obesity in daily practice, self-assessed knowledge and care skills and barriers to optimal care in Austria.

Demographic characteristics of the GPs, along with their overall and subgroup-specific counts and percentages for each question related to screening, prevention, and treatment, are presented in Table 1 and contingency Tables 2, 3, 4 and 5. Of all the GPs contacted, 62 completed the online study, but only 59 did so entirely. These 59 GPs were included in the further evaluation.

Nearly all GPs considered obesity a chronic disease and viewed themselves as the primary contact for its management. Consequently, all GPs felt responsible for preventing or treating overweight and obesity, and all used multiple parameters for screening, prevention and treatment. However, nearly half perceived their education as insufficient to adequately manage obesity, and almost all routinely referred their patients to other healthcare professionals. Approximately 80% of GPs recognized the need for multimodal therapy programs, though awareness of existing healthcare services for obesity management was generally low. From the GP’s perspective, the most significant barrier to effective obesity care was a lack of patient motivation. Each demographic factor, such as gender, professional experience, age, federal state, practice setting, and type of insurance contract, showed a significant association with at least one of the 16 content-related items on screening, prevention, or treatment measures.

Female GPs were approximately three and five times more likely to screen for dietary habits (χ²(1) = 4.17, OR = 3.50, 95% CI: 1.01–12.01, p = 0.041) and physical activity (χ²(1) = 5.85, OR = 5.29, 95%CI: 1.26–22.22, p = 0.016), respectively, than their male counterparts (Table 2). Additionally, they have shown higher odds of referring overweight and obese patients to specialized outpatient care (χ²(1) = 4.54, OR = 3.26, 95%CI: 1.08–9.82, p = 0.033), and expressed a greater demand for more specific resources to support their patients (χ²(1) = 4.51, OR = 4.44, 95%CI: 1.04–19.02, p = 0.034). In contrast, male GPs were over five times more likely to prescribe pharmacotherapy (χ²(1) = 8.84, OR = 5.29, 95%CI 1.69–16.67, p = 0.003, Table 4).

Fisher’s exact test revealed that all other demographic measures (years of experience, chronological age, federal state, practice setting, and insurance status of GPs) showed a significant association with at least one screening or treatment measure. Counts and percentages indicated that more experienced GPs seem more likely to screen for physical activity in obesity prevention (p = 0.029, Table 2), perceived a stronger responsibility for treating obesity (p = 0.019), felt better trained (p = 0.005), and were less likely to seek guidelines for patient support (p < 0.001). Years of experience were also associated with physical activity recommendations as a treatment, with GPs in the 11–20 years’ experience group appearing to recommend it less frequently (Table 4). Chronological age was significantly associated with feeling adequately trained (p = 0.017) and seeking treatment guidelines (p = 0.007). None of the GPs aged 60 or older felt inadequately trained, and only about 1 in 5 sought treatment guidelines (Table 4). In contrast, 3 out of 5 and 4 out of 5 of GPs aged 30–39 reported felt inadequately trained or expressed a need for treatment guidelines. Counts and percentages further revealed that GPs in Vienna were less likely to consider obesity a chronic disease (p = 0.036) and less familiar with multimodal therapy programs than those in Salzburg (p = 0.007, Table 5). Practice settings were associated with considering obesity a chronic disease (p = 0.005), referring patients to psychotherapists/psychologists (p = 0.017), perceiving barriers due to limited knowledge (p = 0.005), and the desire for disease management programs (p = 0.007). General practitioners in primary care units (PCUs) seemed more likely to reject obesity as a chronic condition. Conversely, GPs in solo and group practices seemed to perceive fewer barriers due to limited knowledge and less frequently requested disease management programs compared to those in PCUs and other settings (Table 5). GPs with private insurance contracts seemed to feel best trained to treat obesity (p = 0.023) and were less likely to refer patients to specialized obesity clinics (p = 0.022). They also showed the highest likelihood of offering long-term obesity treatment (p = 0.018) and were the only group that did not request additional support (p = 0.018, Table 5).

Our survey showed that participating GPs assessed themselves as responsible for the care of patients with overweight and obesity and considered the prevention and treatment of obesity a key primary care responsibility. This perceived responsibility aligns with the description of the role of GPs in providing comprehensive and continuous care according to the European guidelines for obesity management in primary care [1].

Despite a strong sense of responsibility, our survey showed that nearly half of the participants did not feel adequately trained to fulfill this task. This was also reflected by the fact that more than half of the participants have not conducted any or only a few long-term therapies so far. The feeling of inadequate education is particularly prevalent among less experienced and younger GPs, suggesting that obesity is not receiving enough attention in medical education and GP training. Data from the United States underline that the low priority given to obesity education in medical schools contributes to a lack of preparedness among medical students to effectively manage patients with obesity [18].

The majority of participating GPs consider obesity to be a chronic disease. This finding is broadly consistent with the results from other studies [17, 19]. Comparing the prevalence rates of obesity to other chronic diseases in Austria, it becomes clear that obesity is indeed one of the most common chronic diseases [20]. Despite the high disease burden, there is limited access to evidence-based therapeutic measures. Several drugs are now approved for obesity treatment and clearly recommended in the guidelines, but costs are generally not covered by health insurance. This fact was also identified by the participants in our study as a major problem for successful treatment.

Most respondents in our study would like a wider range of specialized resources for optimal patient care. As mentioned above, an interdisciplinary care approach is very important in treating obesity. However, in Austria, primary care still predominantly takes place in individual practices [8], which may hinder this approach, as dieticians, psychotherapists, or physiotherapists must be referred to externally. In addition, waiting times for insurance-covered therapy places are long, there are not enough places, or the services are not at all or not fully covered by health insurance.

Even if current services are assumed to be insufficiently available or widespread, it is crucial to note that existing services might not be well-known among GPs. In our survey, 44% of the respondents did not know any multimodal therapy program at all. Particularly in Vienna, such offerings are barely known to GPs. It is unclear whether this is due to differences in local healthcare infrastructure, training deficits, or a lower perceived priority of obesity in urban primary care. However, there is certainly a gap that needs to be closed, as many guidelines also clearly recommend referring patients to such a program when available [11, 13].

Structured DMPs, which were frequently requested by survey participants, could help address this issue by ensuring more structured and continuous care. In addition, DMPs can provide clear guidelines for the treatment of obesity. More than half of the survey respondents indicated that guidelines and educational opportunities are not sufficiently available. The Austrian Obesity Society (ÖAG) recently published a consensus paper with treatment recommendations for doctors of all specialties who treat people with obesity, thus, taking an important step forward [21].

Among barriers to optimal care, GPs in our study identified “lack of patient motivation” as the greatest challenge, a finding similar to that of other studies and surveys [5, 15, 16, 19]. This is neither a structural nor a GP-specific problem and could therefore be solved without a great expenditure of resources. Interestingly, GPs reported the lack of patient motivation across all demographic groups which is particularly concerning, as it is well known that the stigmatization of overweight people, both generally and in the medical context, is a serious problem and can significantly affect treatment outcomes [22‐24]. Future efforts should focus on raising awareness and reducing biases among medical professionals. Current data indicate that around 60 to 70% of all overweight and/or obese people have already experienced weight stigmatization by physicians [23]. In addition, lack of time and inadequate reimbursement by health insurances were frequently mentioned as barriers. These challenges have a greater impact on the publicly funded system. Our results also showed that private doctors were most likely to provide long-term obesity treatment. Addressing disparities between the public and private sectors may be critical to ensuring equitable and effective obesity treatment in all practice settings.

When analyzing the results by gender, female physicians were more likely to screen for lifestyle factors such as dietary and physical activity habits, suggesting that they pay greater attention to prevention, an observation that is supported by existing literature [25]. However, they prescribed pharmacological treatments less frequently and referred patients to specialists more often. Additionally, female GPs expressed a greater demand for specific resources to support patients with obesity, such as specialized outpatient care and further training materials. This may reflect a different approach to obesity management according to gender, but might also indicate the well-known “gender gap”: women tend to underestimate their knowledge and skills, even though there are no objective differences to men [26]. These results are particularly noteworthy, given that there is a female majority in general medicine in Austria [9].

Furthermore, our results indicate that the practice setting plays an important role in the treatment of obesity. GPs in PCUs were less likely to consider obesity a chronic disease and reported limited knowledge about treatment options more frequently than GPs working in other settings. This difference raises the question of whether PCU structures need adjustments to better support obesity care. While patients may have broader access to medical and therapeutic services in PCUs, the continuity of care might on the other hand be reduced, as patients may see different physicians over time, potentially leading to a stronger focus on acute conditions rather than long-term management.

In summary, both structural changes and a greater awareness of the existing challenges in medical practice are needed to sustainably improve the care of people with obesity. The results of our study underscore the need for improved education and easier access to resources. Removing multiple barriers will be crucial to ensure that obesity is treated as the chronic disease that it is and that patients receive the best possible care.

This study has several limitations, and the results must be interpreted with caution. The number of participants is rather small, particularly in some demographic subgroups. The response rate is unknown due to the nature of data collection, which limits the ability to assess the representativeness of the findings. Additionally, selection bias may have influenced the study results, as GPs who participated were likely those with a particular interest in obesity management, potentially leading to an overestimation of awareness and engagement with obesity care. Another limitation is the reliance on self-assessment, which introduces a risk of response bias, as participants may overestimate or underestimate their knowledge and skills. Furthermore, the study’s exploratory nature means that it primarily serves as a foundation for future research rather than providing definitive conclusions. The use of a nonvalidated, self-developed questionnaire is another limitation, as it may not comprehensively capture all relevant aspects of obesity care and may lack reliability and validity, even though the questionnaire was pretested. Finally, we might not have collected all potentially relevant demographic variables, which could have provided further insights into potential influencing factors. To enhance the generalizability of findings, future studies should use larger sample sizes and a clearly defined conceptual model to enable regression analyses exploring the relationships between demographic variables and various aspects of screening and treatment. Additionally, employing validated survey instruments, expanding demographic data collection, and improving response assessment would enhance the generalizability of findings.

Nevertheless, the study provides a picture of the challenges GPs face in managing obesity and how they perceive these challenges in their daily practice. Despite its limitations, the findings align with results from other studies. This underlines the relevance of the topic and the need for further research and targeted interventions to improve obesity care in primary care settings.