Analyzing the approach and treatment adopted by Endocrinology and Metabology expert physicians for patients living with excess weight

Introduction: Body weight increase is a contemporary trend that leads to health issues in different populations worldwide. Social stigma associated with this patient profile has negative repercussions, mainly in physician-patient interactions, which can result in weight gain and in increased mortality rates. Thus, managing this global disease requires better understanding of its multiple aspects, as recommended by international guidelines. Objective: To analyze some aspects of the therapeutic approach adopted by Endocrinology and Metabology-expert physicians to treat patients living with excess weight, based on information available in current guidelines. Material and Methods: Observational, cross-sectional study conducted with convenience sample deriving from the scientific update group “EndoNews”, which is hosted in online platform. Data were collected through structured questionnaire, which was completed by 246 participants. Similar responses were grouped and subjected to Chi-square tests, at 5% Alpha. Results: 72% of physicians reported to have additional difficulties to treat this patient profile (PWD). PWD reports were mostly associated with work environments described as ill-equipped (p-value= 0.009), as well as with the Northern and Northeastern macroregions of practice (p-value= 0.012). In addition, PWD have shown weak belief in long-term therapeutic success (p-value= 0.004) and self-reported this approach as less encouraging (p-value= 0.001). Conclusion: It was possible drawing different profiles for physicians with (PWD) and without difficulty (PND) to treat patients living with excess weight. Factors, such as region of practice and ill-equipped infrastructure, were predictive of such a difficulty. Moreover, certain factors used to analyze participants’ agreement with guidelines have shown that PWD diverged more often from the recommended information. Therefore, reflections about language, therapeutic strategies and infrastructural preparedness to serve these patients were suggested, aiming at subsequent changes in the way physicians approach and treat patients with excess weight.

Obesity is a risk factor for several chronic diseases, 6 such as diabetes, 7 hypertension, cardiovascular diseases, chronic renal disease and certain neoplasms, 8,9 among others. Nowadays, the syndemic generated by biological and social interactions between COVID-19 and obesity has increased the susceptibility of these patients to these diseases and hindered their prognosis. 10 In addition, several biopsychosocial processes -such as political, economic, social and cultural environments, which play strategic role in the analysis applied to the problem and in propositions for interventions -can influence the condition of individuals with excess weight, rather than just influence them and their choices. [11][12][13] Thus, it is essential improving the multifactorial understanding about obesity development and its biological mechanisms to avoid stigma and misguided concepts linked to the assumption that excess weight is exclusively associated with individual features inherent to behaviors such as laziness and lack of willpower.
Therefore, it is necessary bridging the gap between scientific evidence and the conventional narrative of obesity approach, which persists, even in physicianpatient interactions with the health system. 14 Inadequate use of language, either verbal or non-verbal, can lead individuals living with obesity to avoid health care, as well as to interrupt or impair the physician-patient relationship, a fact that can result in weight gain and in increased mortality rates. 14 Individuals living with excess weight internalize these messages, a fact that can trigger physical and mental issues, as well as non-adaptive behaviors. Terms such as obesity and morbid obesity are negatively perceived by patients living with excess weight, even when they are uttered by health professionals. 15 Stigmas emerge through verbal and nonverbal language, as well as through infrastructural unpreparedness, such as lack of properly sized arm cuffs to measure the blood pressure of individuals living with excess weight and properly sized heavyduty chairs where they can sit in. Widths of corridors and other adaptations to environments are also often inadequate. However, they should be designed to enable the free passage of individuals with large abdominal circumference. 13 With respect to verbal language, the vocabulary adopted by health professionals sometimes shows technical unpreparedness to approach patients living with obesity.
In addition, there is considerable evidence to suggest that simply talking about obesity based on a technical, compassionate and prejudice-free vocabulary can lead to weight loss. Such a fact emphasizes that patients should be treated as biopsychosocial beings; thus, all aspects involving them, such as their socioeconomic and mental health condition, 16 should be taken into account in order to bring them health benefits.
Thus, it is necessary adapting therapeutic approaches to fully cover patients' structural dimensions, since social stigma is a frequent factor observed at the time to approach obesity and it has impact on therapeutic outcomes and treatment adherence rates. Therefore, the aim of the current study was to analyze some aspects of the clinical approach to, and of strategies to cope with, this disease by Endocrinology -and Metabology -expert physicians.

MATERIAL AND METHODS
The current cross-sectional observational study is an original, applied research carried out with  Metabology field. 14,16,17 Physicians were identified through their registration number in the Regional Council of Medicine (CRM -Conselho Regional de Medicina) in order to avoid multiple responses from the same participant. The FICF was made available on the platform at the time participants accessed it. They were required to authorize the distribution of the form so the questions could be subsequently made available on the screen.
Questionnaire completion was carried out based on expert physicians' theoretical-practical experiences in approaching patients living with excess weight. Data were collected for further analysis by researchers.

Statistical analysis
Numerical data were described as mean and standard deviation. Categorical data comprised clusters of similar categories, which were formed in cases whose responses recorded very low frequency.
Categorical variables were subjected to Chi-square tests, at 5% alpha, using statistical software (RStudio version 1.4.1106-5 and R version 4.0.5). It is worth emphasizing that the aim of the current study is not to define causal relationships, but to report noteworthy findings for future and more specific research about each of the herein defined variables.

RESULTS
The herein analyzed sample was featured based on information collected through the first section of the questionnaire, as shown in Table 1. Furthermore, questions based on global consensus about the care provided to patients living with excess weight gathered data, which are presented in Table 2.
Based on the current results, 72% of participants self-reported to have more difficulty to treat patients living with excess weight than patients without excess weight (PWD). This variable has generated statistically relevant associations, as shown in Table 3. Physicians who reported lack of additional difficulty to treat patients living with excess weight (PND) recorded higher relative frequencies for the following outcomes than PWDs: they believe in therapeutic success based on lifestyle changes and on long-term medical follow-up with, or without, pharmacological treatment; they believe that the approach adopted during their consultations encourages patients to adhere to and follow the proposed treatment; their work environment is better equipped to deal with patients living with excess weight; they work more often in Midwestern, Southern and Southeastern Brazil.
In addition to the four correlations described in Table 3 and to the information made available in Table   2, the question "what results for the overweight patients do you believe that addressing the topic 'excess weight' during consultations whose main complaint is not about it brings?" (Variable "approach to excess weight") has generated the following results: 74.59% ± 1.20%, for relevant results in patients' clinical history; 16.53% ± 0.87%, for non-significant results in patients' clinical history; and 8.87% ± 0.51%, for uneasiness and partial loss of good physician-patient relationship.
Thus, only 4% ± 2.4% (p-value= 0.007) of PND believe that addressing excess weight during consultations whose main complaint is not about it has negative impact on physician-patient relationship (variable "approach to excess weight"). On the other hand, 11% ± 2.3% (p-value= 0.007) of PWD believe in the likely negative impact of such an approach on physician-patient relationship.
Based on the analysis applied to the association of variables "service network" and "work environment", 73% ± 4.06% of physicians who only work in the private network believe that their work environment is equipped to serve patients living with excess weight, whereas 45% ± 4.4% of physicians who work in both (public and private) networks, or just in the public one, believe so (Table 4).

(COVID-19 and obesity)
Do you agree that "excess weight is an independent risk factor for worse outcomes in (COVID-19) SARS-COV-2 infection"?
243 (98.8%) 3 (1.2%) *Answers collected in the second part of the applied questionnaire. Answers such as "yes, always/yes, often/yes, sometimes" were considered "yes", whereas answers such as "no, never/no, rarely" were considered "no". a Although the question "what results for the overweight patients do you believe that addressing the topic 'excess weight' during consultations whose main complaint is not about it brings?" (Variable "approach to excess weight") is part of the second section of the questionnaire, it was addressed in separate in "Results". Answers collected in the second part of the applied questionnaire. Answers such as "yes, always/yes, oftentimes/yes, sometimes" were considered "yes". "Therapeutic Success" corresponds to the question: "Do you believe in therapeutic success based on changes in lifestyle and on long-term medical follow-up with, or without, pharmacological treatment?". "Influence of the approach" corresponds to the question: "Do you believe that the approach adopted in your consultations encourages patients to adhere to and follow the proposed treatment?". "Work environment" corresponds to the question: "Do you believe that your work environment and equipment are suitable to deal with patients living with excess weight?". There was loss of data in category "Region of practice", since one participant informed a non-existent State.    the analyzed region. 19 The Southeastern, Midwestern and Southern regions present the best regional indicators, and it means that they have the best health service performance. 19 On the other hand, the Northern and Northeastern regions present the worst regional indicators in the country, except for regions covering Northeastern states' capitals; therefore, their health service has low performance. 19 The highest prevalence of PWD was associated with the Northern and Northeastern regions, whereas the highest prevalence of PND was attributed to the Midwestern, Southeastern and Southern regions.
These findings corroborated data on the regional performance of the However, the current study presents some limitations. The cross-sectional design does not allow analyzing the causal effect of these behaviors. Furthermore, the questionnaire was completed based on self-reported information; this factor can generate higher susceptibility to recall biases, which is an intrinsic limitation of cross-sectional studies. In addition, since the literature lacked validated questionnaires on the topic at the time the current research was conducted, and since the validation process was beyond the aims of the authors, the herein analyzed data were gathered through the application of an original questionnaire.
Finally, the current study used non-probabilistic convenience sampling, which resulted in small macro-regional divergence between study and target populations.

CONCLUSION
The aim of the current study was to analyze aspects of the clinical approach to, and of strategies to cope with, obesity by Endocrinology -and Metabology -expert physicians.
Based on the previously presented results and correlations, it is possible concluding that most participants disagreed with what is advocated by several consolidated guidelines and recommendations on the topic. 14, 16,17 As it was evidenced throughout the current study, the approach to, and treatment of, individuals living with excess weight is a multifactorial topic, which was herein correlated to key factors, such as infrastructural preparedness, region of practice, and public or private network.
Moreover, it was possible to find two different profiles among participants, namely: PWD and PND. The PWD group appeared to adhere less to the guidelines than the PND group. Among several instructions available in these guidelines, it is possible highlighting the encouraging approach and greater belief in therapeutic success, which were more associated with the PND group. Finally, it is essential encouraging reflections about language using, strategies and infrastructural preparedness in comprehensive care provided to individuals living with excess weight to enable subsequent changes in physicians' attitude towards their treatment.

ACKNOWLEDGMENT
We are grateful to PhD. Professor Moacir Marocolo Junior, who helped us elaborating the present article and its tables, as well as reviewing it, to enable successfully finishing this project.
In addition, all authors of the current study declare no conflicts of interest. All resources used to elaborate the study were provided by the authors themselves, since it was not funded by third parties.