Attitudes and Reported Practice for Obesity Management in Korea After Introduction of Anti-obesity Agents

Overweight and obesity represent a rapidly growing health threat in both developing and developed countries (1). Primary care physicians play a central role in the systematic assessment and management of obesity (2-7). Guidelines for the management of obesity have been developed in several countries, including Korea (8-10).

Like other Asian countries, Korea has experienced rapid socioeconomic growth with prominent lifestyle transformation over the past several decades. The Korean National Nutrition Survey found that the prevalence of obesity (BMI ≥25 kg/m²) increased from 20.5% in 1995 (11) to 26.3% in 1998 (12). Concern about weight and weight loss is particularly prominent in women, even those of normal weight. Physicians in Korea have become increasingly involved in the treatment of obesity since anti-obesity drugs became available.

Studies in Western countries have shown that general practitioners do not have sufficient relevant knowledge and skills to effectively manage overweight and obesity (5, 13-15). A previous study conducted in urban area in Korea before introduction of anti-obesity agents reported that primary care physicians had little concern about obesity management (16). Although weight problems are increasing in developing countries, there is little information on the attitudes and practices of physicians in regard to obesity management in Asian countries. We therefore investigated the attitudes and practices of primary care physicians in Korea in regard to the assessment and management of obesity after anti-obesity agents became available.

Our results indicated that attitude and practices in managing obesity among primary care physicians in Korea might be far from the guideline (8-10). Although the prevalence of a BMI ≥30 kg/m² is much lower in Korea (2.3%) (12) than in Western countries (22.3%) (8), the present results indicate that primary care physicians in Korea tend to over-prescribe anti-obesity medications without appropriate evaluation or without allowing enough time for diet and exercise treatment to take effect in obese patients.

Before anti-obesity medications came to market, primary care physicians in Korea were less concerned about the management of obese patients, even those who were severely obese or who had obesity-related health problems (16). This lack of interest in obesity management prior to the advent of anti-obesity medications may have been due to the fact that in Korea there is no insurance reimbursement for nonpharmacologic treatments such as diet and exercise therapy, making such treatments less of a concern for physicians.

Following the availability of anti-obesity medications in Korea in 2001, interest in obesity management increased both among patients and physicians. Marketing of these agents led patients to believe that they could control their weight with a "magic bullet". Moreover, physicians readily prescribed these medications to their patients because there is insurance reimbursement for the prescription fee, although not for the medications themselves.

We found that many primary care physicians in Korea were unfamiliar with the definitions of obesity and abdominal obesity, with only half being aware of the definition of obesity according to the Asia-Pacific regional obesity guidelines. In addition, the physicians surveyed tended to conduct inadequate evaluation of obese patients. Although biennial measurements of BMI and waist circumference are recommended for the evaluation of obesity and abdominal obesity in asymptomatic patients (8), only 15% of physicians measured a patient's weight and height at the initial visit, and only 5% measured waist circumference.

Even in apparently obese and overweight patients, many physicians did not adequately assess anthropometric measurements, with only about 50% of physicians measuring BMI and 20% measuring waist circumference in obese patients. Since obese patients have higher rates of prevalence and mortality from cardiovascular disorders (17-19), evaluation of risk factors and the patient's medical history is needed. Our findings indicate that physicians in Korea are not carrying out sufficient evaluation of cardiovascular risk factors in obese patients.

Although about two-thirds of the physicians reported recommending diet and exercise therapy, this was lower than the 92% of family physicians in Germany who attached great importance to nutritional counseling (20). In managing obesity, diet and exercise therapy is usually tried for 3 to 6 months before initiating medication (1, 8-10). It has been shown that, in the management of chronic diseases, lifestyle modification is more effective than pharmacotherapy (21, 22). Although only about 30% of our subjects regarded pharmacotherapy as effective and over 60% agreed that these anti-obesity agents were too expensive, approximately 50% of the physicians indicated that they would prescribe an anti-obesity medication at a patient's initial visit if the patient was willing to lose weight. Most of the surveyed physicians reported seeing over 50 patients per day, indicating that there are severe constraints on their time. These time constraints may explain why primary physicians in Korea tend to take the easier and less time- and labor-intensive route of prescribing a drug rather than recommending some type of behavioral therapy. Our results on physicians in Korea differ from those obtained in a study of primary care physicians in Israel, which found that only 4% of doctors recommended using regular anti-obesity drug therapy (23).

Approximately 90% of the physicians surveyed in the present study reported being asked to prescribe anti-obesity medication by nonobese patients, and 70% of these physicians actually prescribed the medication. These findings indicate that there may be a serious risk of abuse of these drugs. In addition, about one quarter of the physicians did not hesitate to prescribe a combination of anti-obesity medications, even though there is no evidence showing that combinations are more effective than individual agents. The management of obesity by Korean physicians thus differed considerably from basic obesity management guidelines (1, 8-10). Obesity experts in the U.S., where the prevalence of obesity is high, regard medications as less important than exercise in treating obesity (24).

Physicians who were older or who practiced in rural areas had less interest in obesity management. In contrast, younger physicians or those who worked in urban areas tended to overprescribe anti-obesity agents. Although family physicians have been reported to be more aggressive in the treatment of obesity than other physicians in the United Sates (14), we observed no significant differences in attitudes or reported practice according to specialty.

Our study had several limitations. The response rate of physicians was low, although we regard those who participated as adequate representative subjects selected by systematic random sampling among family physicians and internists in Korea. In addition, use of a self-reporting questionnaire may have led to an overestimation of the rate of physicians' evaluation of obesity and/or an underestimation of the rate of physicians' prescription of anti-obesity medications.

In conclusion, we have found that primary care physicians in Korea do not sufficiently evaluate obesity in their patients, yet they over-prescribe anti-obesity medications. Anti-obesity medications are not covered by insurance in Korea, and thus cost a patient about 83 to 125 US dollars per month. Over-prescription of anti-obesity medications adds much to the national cost of medical care (25). Our findings suggest that primary care physicians in Korea need more education about obesity and its management, with an emphasis on prudent prescription of anti-obesity agents. This should enhance the contribution of primary care physicians to the appropriate management of obesity.