Italian Survey on Perception of Obesity and Bariatric and Metabolic surgery: a comparison between general practitioners and obese patients

Purpose Obesity is a pandemic, chronic and relapsing disease with several treatment options. The aim of this work was to investigate the level of awareness that people with obesity (PwO) have of their own condition and the level of knowledge regarding possible treatments available. To compare and contrast collected data on PwO with data obtained from general practitioners (GPs). Methods Data for this cross-sectional, non-interventional, descriptive study was collected via an online survey (CAWI methodology). 521 people were interviewed: 320 PwO and 201 GPs. Survey data were summarised in percentages and a 95% Confidence Interval (CI 95%). Results There is a lack of awareness of obesity as a disease among PwO. Firstly, most PwO (60%, 95% CI: 54%-65%) consider obesity to be an aesthetic problem and secondly a health problem (59%, 95% CI: 54%-65%). Conversely, 80% (95% CI: 74%-85%) of GPs consider obesity as a disease. The survey focus on the knowledge of bariatric and metabolic surgery (BMS) as a possible treatment option showed that only 12% of PwO (95% CI: 8%-16%) declared they had never heard about it, while 88% (95% CI: 84%-91%) declared they knew about it. Similarly, 95% (95% CI: 91%-98%) of GPs claim to know about BMS, but they recommended it only to 5% (95% CI:2%-9%) of their patients. In treating obesity GPs considered BMS less efficient than diet and physical activity (83% (95% CI: 77%-88%) vs 90% (95% CI: 84%-93%)) and to be indicated mainly for patients with comorbidities which cannot be controlled otherwise. Conclusions Our results indicate that implementing awareness campaigns for patients and GPs is currently as essential as providing structured programmes for obesity treatment. Moreover, it is still necessary to sensitize GPs on BMS which should be considered a standard obesity treatment option in selected cases. CI: for CI: In the 88% (95% CI: 82%-92%) of patients with BMI ≥ 40 kg/m2, eligible for bariatric surgery, while 21% (95% CI: 15%-27) evaluated BMS for patients with BMI between 35 and 39.9 kg/m2. 70% of GPs considered BMS indicated for obese patients with comorbidities without any other therapeutic option. The pathologies were retained contraindications BMS circulatory (59% (95% CI: (53% CI: (36% CI: peripheral CI:


INTRODUCTION
The global obesity epidemic continues its unrelenting advance, with the number of people with excess body weight reaching >2 billion, ∼30% of the world population. No less than 3.4 million people die every year due to obesity comorbidities. [1] On the basis of recently published data [2] in 2017 in Italy, there were more than 23 million people who had excess body weight above the age of 18, of which approximately 18 million were overweight (35.4%) and over 5 million were obese (10.5%) (11.5% men; 8.9% women). In the period of time between 2001 and 2017, obesity rose primarily among people with a low level of education (from 11.9% to 14.2%) and an intermediate level of education (from 6.3% in 2001 to 9.8% in 2017) while it remained more or less stable for those with a high level of education (from 6.9% to 6.6%). Diabetes (DM), hypertension (HTC) and cardiovascular diseases are present in 25.4% of the general Italian population and in 46.3 % of obese population (DM 6.7% vs 14.6%; HTC 21.2% vs 39.4%).
Due to its complexity obesity is a serious challenge for public health. To all effects, this condition is a chronic and relapsing disease with a complex pathogenesis. [3,4 ] In fact, there is no gene or single cause that can explain all the alterations which characterise this pathology, instead there are multiple factors which together contribute towards determining it. [5,6] Consequently, finding a single solution to the problem is not a path to take but it needs a synergistic and multidisciplinary approach. [7,8,9] Althought available evidence supports multi-component interventions as effective in obesity prevention, the adequate management of this condition still represent a complex challenge.
Moreover, in the last years the stigma associated with obesity has been considered the major contributor to negative health outcomes and behaviors that can promote and exacerbate obesity, wich is usually represented through negative stereotypes, unsuitable language and images. [10] Patients with obesity (PwO) are often held solely responsible for their condition [2], and this bias leads to underestimate obesity as a disease with a strong clinical, social and economic impact.
A recent survey carried out by the Centre for Social Studies and Policies (CENSIS) [11] showed that a third of the Italian population feels correct to penalise people, such as smokers, alcoholics, drug addicts and even people with obesity, who compromise their health through harmful lifestyles, with additional taxes or limitations to health care access within the National Health System.
Despite the fact that the World Health Organisation (WHO) considers obesity a chronic disease and the concept is recognised as such by many national and international scientific organisations [4,8,12,13,14 ] , only Portugal in the old continent has acknowledged this at a legislative level. [2] In the last few years, Italy has implemented policies to contrast the obesity phenomenon, especially within national and regional chronic disease prevention programs, which represent winning strategies in the battle against this increasing social health-emergency. Beside prevention, also several approaches are usually adopted in obesity treatment. Among them, Bariatric and Metabolic Surgery (BMS) is considered the most effective tool not only for weight loss but also for obesity co-morbidities in the short, medium and log-term. Its greater effectiveness compared with conservative medical strategies has been demonstrated over the years by systematic reviews and meta-analysis of randomised controlled trials. [15] . Despite scientific evidence, access to BMS remains incredibly low. The total number of bariatric/metabolic procedures performed in the world in 2016 was 685,874. [16] In the same year, according to the WHO, the number of obese people in the world was 650 million. [17] This means that in 2016 only 0.1 % of patients who were eligible for surgery were operated including a variability of between 1.9 % in the Netherlands and 0.001% in China and Japan.
Our study aim to investigate, on a national scale, the level of awareness that the Italian PwO have of their condition and the level of knowledge regarding the possible treatments available. Moreover, another endpoint is to compare and contrast collected data on PwO with data obtained from Italian general practitioners (GPs).

MATERIALS AND METHODS
This study was designed and implemented by researchers in the Ipsos Italia Healthcare team with the non-conditioning contribution of Johnson & Johnson Medical S.p.a. This research involved a cross-sectional, non-interventional, descriptive study that collected data via an online survey. The interviews were carried out in July -August 2017.
The aim of the study was to verify the obesity phenomenon, how it is experienced and managed using and comparing data collected from a survey carried out on a sample of Italian people with obesity (PwO; Body Mass Index -BMI ≥ 30 Kg/m 2 ) and on a representative sample of Italian general practitioners (GPs).
As far as PwO is concerned, the questionnaire was administered to 4000 families. 7323 members of these families, representative of the Italian population aged 18 and over were screened for weight, height and BMI. 48% of these subjects were overweight or obese, in line with the epidemiologic data reported in the "1st Italian Obesity Barometer Report" 2 . Among them, a statistically significant sample of 320 panelists was randomized, maintaining the representativeness of the Italian population.
Regarding GPs, the survey was administered to 201 panelists.
All the panelists provided informed consent electronically before they took part in the survey.

People with Obesity (PwO)
PwO (BMI ≥ 30 Kg/m 2 ) who participated in the survey were selected via screening questions out of a representative panel of the Italian population according to geographic area parameters, gender, age and level of education (source: National Institute of Statistics -Istituto Nazionale di Statistica -ISTAT). The partecipants to the survey filled in the survey themselves online and in their own home.
The survey, which lasted on average 15 minutes, addressed the following topics: obesity experience, management of the problem, doctor's consultation and their role in the management of obesity, knowledge of BMS, willingness to undergo surgery and search for information on the subject of weight.

General Practitioners (GPs)
The data were collected using the CAWI (Computer-Assisted Web Interview) technique. We used a specially designed e-questionnaire as our research tool, with branched tree structure, customized on the basis of the answers of the interviewees. A specific link was sent via email that the respondent proceeded to complete independently.
This method allows reaching a large number of respondents in a very limited time interval. There are no geographical limits of targets, but those who were not very familiar with computers and technology were excluded. Moreover, partecipants are autonomous in completing the questionnaire and can do so at a time of their choice and take all the time they need to respond. It offers the best efficiency in terms of costs and timing. Any limits are related to the lack of comparison with the interviewer and the risk of abandonment by the respondent without having completed the interview.
The partecipants were asked: • multiple choice questions.
• ranking questions, or rather questions in which is requested to put in order a sequence of options/answers according to the order of importance or prevalence.
• questions whose answer requires the interviewee to enter a numeric data. For example: what's your weight?
• questions of satisfaction and appreciation. In particular, this type of questions includes 5 different answers: two with positive connotation, two with negative connotation and one neutral. It was used the Likert's scale associated with 5 categories of answers, in a scale from 1 to 5 points (where 1 is assigned to the answer with the major negative connotation and 5 refers to the answer with the major positive connotation).
In particular, the survey administered to PwO consisted in 5 sections, investigating different obesity-related issues.
The first section encompassed a cluster of questions concerning overweight, the impact of obesity on patients' lifes and obesity management: how participants understand and perceive obesity, relationship between obesity and other health issues, participants' opinion on treatments to lose weight and routinely problems associated to obesity. The first section explored anthropometric and anagraphic characteristics of GPs' obese and overweight patients.
Furthermore, comorbidities associated to such condition and causes leading to obesity were investigated.
Afterwards, obesity treatments were considered in a second section: GPs' suggested actions towards weight loss and their effectiveness, if patients are monitored by specialists or GPs, and patients' goals.
In the third section surgical treatments were examined: the knowledge of GPs about BMS and its effectiveness, comorbidities associated to obesity and BMS, whether GPs' obese patients were willing to undergo BMS, if GPs suggested or discouraged their patients to undergo such surgical treatment and what worries obese patients about BMS.
GPs' satisfaction over surgical treatments and what drove their choice to such treatments were analyzed in the fourth section: what prompt GPs to suggest or to discourage BMS.
Last section investigated GPs' current knowledge about surgical treatments: specialized surgical centers, if GPs wanted to apprehend more about BMS and specialized centers.
In both surveys the questions were administered all in one session with topical dividers.

Elaboration of data and results
A descriptive analysis was carried out to evaluate survey data of 320 PwO and 201 GPs. Categorical variables were shown by percentage and Confidence Interval 95% (CI 95%), while continuous variables were shown by mean and 95% confidence interval. The differences between categorical variables were tested with the Chi-square test. All tests were two-sided and considered statistically significant at the 0.05 level. A sub-analysis was carried out to compare data of 180 patients with BMI between 30-34.9 kg/m 2 (group A) and 140 patients with BMI ≥35 kg/m 2 (group B). All analyses were performed using SAS 9.4 (SAS Institute, Inc, Cary, NC, USA).

DISCUSSION
In this study we carried out a survey on a sample of 320 PwO (BMI ≥ 30 kg/m 2 ), representative of the Italian population, analysing their level of knowledge regarding obesity as a disease and the possible treatments available. The results were compared with the answers obtained from a representative sample of 201 GPs from all over Italy regarding the same topics.
The survey revealed that only 24% of PwO admitted to being little to not at all satisfied with their lives, with an increase of dissatisfaction as BMI increased and the condition of being obese increased (Tab.1). In addition, most PwO considered obesity to be firstly, an aesthetic problem and secondly, an issue affecting health, physical efficiency and psychological distress (Tab. 2). The higher the BMI, the higher the awareness that obesity is a disease, while, paradoxically, the perception of obesity as an aesthetic problem does not change.
The high aesthetic value of distress related with obesity can partly be due to social contextualisation in which being overweight/obese can be a penalising factor not only as far as health is concerned but also from a relational and psychological point of view. The failure to adhere to the aesthetic archetype of thinness ends up discriminating obese people, who are attributed with personality and behavioural traits to be stigmatised [2].
Comparing data in our study with data found in the US ACTION (Awareness, Care, and Treatment in Obesity management) study [18] and the ACTION-IO (International Observation) study [19] , we noticed that Italian patients have a lower tendency to acknowledge obesity as a disease (59 % vs 65% US ACTION -68% ACTION-IO, respectively).
This finding was even more emphasized by a recent paper on the Italian data extracted from the ACTION-IO study [20] .
Moreover, in a survey carried out by the European Association for the Study of Obesity (EASO) [21] , obesity was recognised as a disease only by 46 % of PwO interviewed, but if only Italian interviewees are taken into consideration within the EASO study, the result goes up to 62%, a figure which can be overlapped with the results in our study. The EASO study also showed that Italian interviewees were less aware with respect to other European citizens with regards to obesity as a cause and/or a contributing factor of diabetes, joint and spinal column pathologies, hypertension, heart attack and tumours.
Italian GPs were, to all effects, in line with the international scene regarding obesity as a chronic, relapsing disease (80% vs 80% US ACTION -88% ACTION-IO, respectively). It is interesting to note how Italian GPs acknowledge the coexistence of social models and stimuli which favour an incorrect diet and a genetic/hereditary component, at times associated with a psychological fragility, as the main causes of obesity. Endocrine disease and/or organ or body disfunction have a lower percentage and were retained less determinant. Surprisingly, only 4% of GPs considered a sedentary lifestyle a real cause for obesity. On the other hand, patients interviewed attributed an important role to heredity regarding the onset of the disease, followed by the conditioning factor of today's society and individual psychological fragility (Fig. 2). PwO's perception of feeling partially responsible for their condition of obesity, as weak, without self-control, seems to be one of the major reasons to explain their resistance and/or failure during various dietary treatments [22] .
This difference in perception of obesity as a disease is also reflected in the goals that PwO had set themselves with respect to those set by a GP for obesity treatment (Fig. 4). For patients, their main objective was to improve their quality of life, followed by weight loss and lastly, control/ameliorate obese-related pathologies. GPs, on the other hand, knew that to contrast obesity the main aim is to control/ameliorate comorbidities followed by improving quality of life and only marginally, reducing weight.
In our study 38% of PwO had not done or was not doing anything to lose weight. This is a higher rate than in the EASO study [20] which reported 17%.
The current study shows that the main motivations that prompted PwO to not want to modify their current condition were: lack of willpower and the inefficacy of previous treatments in weight loss maintaining in the long term. The chronic and relapsing nature of the disease induces patients to give up after repeated failure of diet attemps. Another important factor that often contributes to giving up, as demonstrated in one third of PwO referred a judgment of other people about their physical state which caused a great stress. Social stigma was and continues to be much discussed in literature. [23] This data suggests that there is a need to offer structured, efficient treatment not only for obesity prevention but also for its cure.
Among the remedies taken by PwO there was a prevalence of "self-made" diets followed by "professionally-directed" weight loss diets and regularly doing physical exercise. The use of medically prescribed drugs or BMS was only taken into account by a small minority of PwO. In addition, the rate of dissatisfaction with results obtained was very high, in fact only 11% of PwO was satisfied.
Paradoxically, the advice given by GPs to obese patients was the same as what the patients had in part done but with poor results: to follow a tailored diet plan and to do more exercise. Only 22% of patients were advised to go to a specialist (dietologist, nutritionist, endocrinologist), only 10% to go to a specialist obesity care Centre and only 5% to go to a BMS specialist Centre. GPs retained that a tailored diet associated with exercise was the most efficient treatment in terms of weight loss, which is in contradiction to their own belief that a sedentary lifestyle is the cause of obesity in only 4% of the cases.
In treating obesity, GPs considered BMS less efficient than diet and physical activity (83% (95% CI: 77%-88%) vs 90% (95% CI: 84%-93%)) and to be indicated mainly for patients with comorbidities which cannot be controlled otherwise, which means that BMS is considered as the last therapeutic chance for complex patients.
In addition, GPs place little trust on pharmacological treatments for obesity. This data is consistent with what PwO declared as being the advice received from their GP to deal with obesity. A similar trend was also described in the US ACTION study [18] .
This study revealed that BMS was known as a treatment by the patients and the physicians interviewed. Despite the fact that BMS is the most effective treatment in producing sustainable weight loss and improvements in obesity-related comorbidities 15 and despite that 95% (95% CI: 91%-98%) of GPs claim to know about BMS, they recommended it only to 5% (95% CI: 2%-9%) of their obese patients.
There was a lack of knowledge among GPs concerning the pathologies to be considered contraindicated for BMS.
Paradoxically, what was considered a contraindication in reality are precisely those pathologies that actually represent an indication for BMS (if associated with obesity), such as vascular problems, diabetes, sleep apnea and hypertension.
PwO stated that when surgery had been proposed as a treatment option, the suggestion came from their GP only in 14% of cases, confirming GP's reluctance to indicate BMS. The prevailing motives that prevent GPs from suggesting BMS were: post-surgery adverse effects, weight regain in the long term and any complications during surgery. This data suggests that BMS is still often perceived as a dangerous surgery and highlights as certain preconceptions are deeply rooted in part of the medical profession.
The introduction of laparoscopy, of high-performance surgical instruments and the continuous development of increasingly refined surgical techniques, allowed the development of ever higher security standards, guaranteeing a rapid post-operative recovery and an excellent quality of life over the years. [24] Doubts preventing PwO from undergoing bariatric surgery were similar to those expressed by GPs. The majority of PwO also thought that BMS is a path to be taken only in specific cases and as a last therapy option.
If it is generally accepted among clinicians the obesity is to be regarded as "a chronic, relapsing, multi-factorial, neurobehavioral disease, wherein an increase in body fat promotes adipose tissue dysfunction and abnormal fat mass physical forces, resulting in adverse metabolic, biomechanical, and psychosocial health consequences" [ 25 ] , then patients with obesity should receive more structured treatment than a simple "eat less and exercise more".
To further understand some of the dysfunctional dynamics involved in the management of obesity, it may be useful to make a parallelism between diseases. Lung cancer is a fatal disease if not adequately treated, which involves smoking as a well-known risk factor. Obesity is a potentially fatal disease which has overeating and sedentariness as known risk factors. If a doctor visits a patient affected with a suspected lung lesion and simply recommended giving up smoking and did not refer the patient to a specialist, a pneumologist/thoracic surgeon/oncologist, he/she certainly delays the diagnosis of the disease and worsens the prognosis, not allowing the patient to access care. Not only would the doctor not have done his/her job but he/she would be legally liable. Attitude towards therapy in the treatment of obesity seems to continue to be different. Despite obesity being universally recognised as an endemic pathology, it continues to often be treated as a simple risk factor [26] .
"Globesity" is today responsible for a total cost of approximately 2 trillion dollars, which corresponds to 2.8% of the global gross domestic product. What is more, the indirect costs, in terms of loss of productivity and related gains, are at least double the direct costs (hospitalisation and medical care). It is estimated that in 2012 in Italy, excess weight accounted for 4% of national health expenditure, a total of approximately 4.5 billion euro, a trend that is in constant growth. For all these reasons, obesity must be considered to all intents and purposes as a health problem with high social, economic and political priority, acknowledging the fact that it is a highly disabling disease [2] .

Strenght and limits
This study highlights how the perception of obesity as a disese is actually low among a sample of subjects affected by obesity, representative of the Italian population. A limitation of the study may be the low sample size, due to budget problems. However, the number of patients recruited is statistically significant. Another important finding emerged by this survey is how BMS is still little recommended by Italians GPs as a standard treatment for obesity in selected cases.

What is already known on this subject?
In 2018, obesity was recognised as a disease only by 62 % of PwO interviewed in the ACTION-IO study.

What your study adds?
This survey support previous results and after 3 years strongly suggest that it is still necessary to raise the awareness on obesity as a disease.
Furthermore, it specifically focuses on surgery, underlining how BMS is still not recommended by Italian GPs as a standard treatment for obesity in selected cases. Hence the need to implement campaigns and programs of correct information for both patients and GPs.

CONCLUSIONS
Obesity is, to all effects, a chronic and relapsing disease with complex pathogenesis that has reached a level of pandemic spread [2,4,8,12,13,14]. However, from our study it emerged that there is a lack of awareness of obesity as a pathology among PwO. In addition, despite BMS being the most effective treatment in producing sustainable weight loss and improvement in obesity-related co-morbidities [15] , up to now only 0.1% of BMS eligible patients have been surgically treated [17] . Our study shows that although 95% of GPs claim to know about BMS, they recommended it only to 5% of their obese patients, considering BMS less efficient than diet and physical activity and to be indicated mainly for patients with comorbidities which cannot be controlled otherwise.
In view of the data collected, we believe that it is a priority to continue with the campaigns to raise awareness on obesity as a disease and not as an aesthetic problem to be stigmatized. Moreover, it is of great importance to involve GPs more in the management of obesity of their patients, suggesting structured treatments, on a multidisciplinary level, within specialist Centres for obesity cure. It is also necessary to sensitize GPS to consider BMS as a standard treatment option for obesity, perhaps via training and refresher initiatives.

Funding
This study was partially supported by Ricerca Corrente funding from Italian Ministry of Health to IRCCS Policlinico San Donato.

Conflict of interest
The authors declare that they have no conflict of interest.

Ethical approval
In Italy, ethical approval was determined to be non-essential for a study of this nature based on regulatory standards and previous studies. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent
All respondents provided electronic informed consent prior to the initiation of the screening questions and survey.

Author contributions
IPSOS recruited, collected and analyzed the data, and designed the study (E.DS), D.T and CLA.G interpreted the data and wrote the first draft of the manuscript, CLA.G. and C.A. critically reviewed the draft of the article, S.B. supervised the statistical analyses, C.A. and A.G. are the guarantors of this work and, as such, had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analyses. All authors read and approved the final manuscript.

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