Consulting Obese and Overweight Patients for Nutrition and Physical Activity in Primary Healthcare in Poland

The aim of this study was to evaluate the dietary and physical activity counseling provided to adults by family doctors. Predictors of counseling in primary healthcare were identified. A cross-sectional study was conducted from January 2020 to December 2021 among 896 adult primary care patients in the city of Łódź [Lodz], Poland. Almost 36% of the respondents were advised to change their eating habits, and 39.6% were advised to increase their physical activity. In a multivariate logistic regression analysis, people in poor health with chronic diseases related to overweight and obesity and with two, three or more chronic diseases, respectively, received advice on eating habits from their GP twice and three times more often than people in good health with no chronic conditions (OR = 1.81; p < 0.05 and OR = 1.63; p < 0.05; OR = 3.03; p < 0.001). People in the age groups 30–39 years and 40–49 years (OR = 1.71; p < 0.05 and OR = 1.58; p < 0.05), widowed (OR = 2.94; p < 0.05), with two, three or more chronic diseases (OR = 1.92; p < 0.01 and OR = 3.89; p < 0.001), and subjectively assessing overweight and obesity (OR = 1.61; p < 0.01) had a better chance of receiving advice on physical activity. The study found a higher proportion of advice on diet and physical activity provided to overweight and obese patients by primary care physicians than in other studies; however, still not all receive the necessary counseling. GPs should advise all patients not to become overweight and obese, not only those already affected by the problem.


Introduction
Overweight and obesity are one of the main risk factors for chronic diseases, including cardiovascular diseases, diabetes, certain cancers, disorders of the musculoskeletal system, and disability [1][2][3]. Obesity is a serious public health problem with increasing social, health, and economic costs [4,5].
Worldwide, the number of people who are overweight and obese has grown in all age groups and is expected to rise even further over the next decade. According to the World Health Organization (WHO), in 2020, the number of adults with overweight was 1.9 billion, and those with obesity 0.6 million [6]. In 2019, 52.7% of the adult population in the European Union were overweight, and among them, 17% were people suffering from obesity [7]. The percentage of overweight adults varies across countries, with the highest proportions in Croatia and Malta, where 65% of adults were considered overweight in 2019. In Poland, this percentage is 58.1%, while the aforementioned European average is 52.7% [7,8]. It is estimated that in total 50-70% of the adult Polish population are overweight and obese, including over 25% of obesity cases. In 2020, 54% of Polish people were overweight (46% of women and 64% of men) [9]. The high body mass index (BMI ≥ 25) in Poland accounts for 14.2% of deaths (15.3% of women and 13.1% of men) [9]. These data indicate that overweight and obesity are significant problems in the Polish population; therefore, it is of Lodz, where the inhabitants live even shorter than those residing in small towns [9]. In the past, the WOBASZ I (2003)(2004)(2005)(2006) and WOBASZ II (2013-2014) Multicenter National Population Health Examination Surveys were conducted in Poland. The surveys also covered the inhabitants of Lodz [26].
The number of general practitioners in the Lodz province is 433 (as of 31 December 2019) [27]. According to data received from the National Health Fund, in 2020 and 2021, there were 211 primary healthcare entities in the city of Lodz. Both the number of entities and the number of primary care physicians in Lodz are low, as is the case in the whole territory of Poland. As compared to other countries, Poland has the lowest share of GPs (which is only 9% of all specialists), except for Greece (6%) [28].
From the list of 211 primary health care facilities, every fifth clinic was selected randomly. The selection process was conducted to guarantee geographical representation. Thirty-four primary healthcare facilities agreed to conduct the study among their patients. From the randomly selected clinics, eight refused to participate.
The required sample size was calculated for two-sided tests at a significance level of 0.05 and power for selected alternative hypothesis equal to 0.8. For OR = 1.5 and a hypothetical proportion of controls with exposure equal to 30%, about 855 participants are required.
Adults over 18 years of age who consulted a doctor in primary care and agreed to participate in the study were included in the study. Individuals under the age of 18 years and adults who did not give their consent were excluded from the study. The participation rate was 80%.
On Monday and Wednesday in the morning and on Tuesday and Friday in the afternoon, every fifth patient leaving the doctor's office was randomly selected and asked to enter the study. In case he/she refused consent another sixth patient was selected. The study included 896 patients who gave their written consent to participate in the study, whereas 221 refused to participate. In each facility that agreed to examine patients, 26-27 individuals were examined. At the same time, a questionnaire survey was conducted among family doctors. The results will be presented in the following articles. The study was approved by the Bioethics Committee of the Medical University of Lodz on 18 September 2018 (RNN/315/18/KE).

Study Variables
The principal researcher conducted data collection. The research tool was an anonymous paper-based questionnaire including mainly closed questions. It was based on standardized questions that had been used in other studies [29,30].
Face-to-face interviews were conducted. The survey included questions regarding sociodemographic features and information on appointments with primary care physicians and nurses, as well as characteristics of lifestyle factors.
The following socio-demographic variables were selected for the study: gender, age, education, marital status, and employment status. The article covers two sections out of seven included in the questionnaire, i.e., information about appointments with a primary healthcare doctor and information on the role of a physician as a provider of healthy lifestyle.
Information on the family doctor talking to the patient about eating habits and physical activity was obtained based on the following survey questions: "Has the family doctor ever talked to you about your eating habits or diet?", and "Has the family doctor ever talked to you about physical activity and exercise?". Additionally, the respondents were asked whether the topic was initiated by them or a family doctor.
Information on receiving advice from a family doctor was obtained based on the following questions: "How often does your doctor advise you on a healthy diet/proper nutrition", and "How often does your doctor advise you to be physically active?".
People who have never been counseled on eating habits, diet, or physical activity are respondents who answered "never" to the above questions, and those who answered "sometimes", "often", or "always ", were classified as patients who received counseling in the above-mentioned issues.
The answer "sometimes" concerned less than 50% of advice during all medical appointments in primary care and "often" 50% or more of advice during all medical appointments in primary care, whereas the answer "always" related to advice at each visit to a primary care physician.
The questionnaire also included questions about the frequency of measuring body weight on a scale, height, and waist circumference, and calculation of their body mass index (BMI) by a family doctor. The possible options were: (1) at each routine visit, (2) annually, (3) if clinically indicated, and (4) never.
The respondents were asked about chronic diseases related to overweight and obesity, such as coronary artery disease, hypertension, type II diabetes, chronic obstructive pulmonary disease or asthma, and others, treated by a family doctor. Based on the answers given, they were divided into four groups: no disease, one, two, and three or more diseases.
The study participants were also asked about their subjective assessment of being overweight and obese. Table 1 presents the characteristics of the studied population.

Statistical Analysis
Descriptive statistics and the distribution of the studied variables were carried out. The data were presented as numbers and percentage rates. Categorical variables as a percentage were compared using the chi-square test. Single-variable and multivariate logistic regression analyses were performed to obtain ORs (odds ratios) and 95% confidence intervals (CIs) of each indicator for diet and exercise counseling. Variables with p values of 0.1 or less from the univariate analysis were included in the multivariate model. A p-value of less than 0.05 was considered statistically significant. The analyses were carried out using STATISTICA version 13.3. Missing values were removed in pairs.

Characteristics of the Studied Population
Among the respondents, 25.8% were men and 74.2% were women ( Table 1). Most of the study participants had secondary (56.9%) and higher (31.9%) education levels. The most numerous groups of respondents were people aged <30 years (28.6%) and the group of those aged 40-49 years (24.0%). Five percent of the respondents were unemployed, and professional activity was reported by 61.6%. Out of 896 adult primary care patients in the city of Lodz, 25.4% were overweight and 19.5% were obese. In addition, 23.7% of the respondents admitted that they suffered from chronic diseases, i.e., cardiovascular diseases, and type II diabetes (Table 1). In a subjective assessment, 32.8% of the respondents stated that they were overweight or obese. The response rate was high (80%) as compared to other surveys conducted in Poland. There was no lack of data in the responses of the subjects included in the analysis.

Advice on Nutrition and Exercise
A total of 36% of respondents consulted their primary care physicians about their eating habits or diet, and 39.6% consulted them about physical exercises. Obese respondents were more likely to talk to their family doctor about nutrition and physical activity as compared to overweight people ( Table 2). In addition, 60% of obese and 39.2% of overweight patients spoke to their doctors about their eating habits or diet. Among the study group, 60% of obese and 41% of overweight subjects spoke about physical activity and exercise.
Approximately 71% of the discussions on eating habits and diet, as well as physical activity and exercise, were initiated by the family doctor. The family doctor opened a conversation about eating habits or diets more often in obese and overweight people (77.1% and 75.3%, respectively). Similarly, a conversation about physical activity and exercise was more often undertaken by a physician for obese and overweight people (76.2% and 66.7%). Overweight and obese respondents who talked to the doctor most often indicated that the family doctor sometimes advised them on diet, proper nutrition, and physical activity.
Among the respondents, 29.1% of obese and 23.4% of overweight patients indicated that their doctors sometimes advised them on a healthy diet or proper nutrition, while 27.4% and 23.8% of the respondents received advice on physical activity. In addition, 30.8% of obese and 22.0% of overweight patients sometimes received general advice on changing their diet, exercise, or weight loss; 29.7% of obese and 20.7% of overweight patients were given detailed advice on diets/nutrition; and 29.1% and 20.7% were given advice on physical activity. Sometimes the family doctor gave detailed advice on weight control (in 32.0% of obese and 18.1% of overweight patients).
The association between personal characteristics (age, gender, education, marital status, professional status, place of residence, and financial situation) and counseling was examined using logistic regression analysis. The odds ratio (OR) and a 95% confidence interval (Cl) were used to measure the strength of the association. The results of the univariate and multivariate logistic regression analyses for GP counseling with sociodemographic and health correlates are presented in Table 3.
In the univariate analysis, the variables such as a male gender, age 60+, and two chronic diseases were statistically significant (p < 0.001), and statistically insignificant in the multivariate logistic regression analysis.
In the multivariate logistic regression analysis, variables that were statistically significant in the univariate logistic regression analysis were considered.
In the multivariate logistic regression analysis, individuals in poor health with chronic diseases related to overweight and obesity and with two chronic diseases and three or more chronic diseases, respectively, received advice on eating habits twice and three times more often from their GP than people in good health with no chronic conditions (OR = 1.81; p < 0.05 and OR = 1.63; p < 0.05; OR = 3.03; p < 0.001). The widowed (OR = 2.43; p < 0.05) and those with subjectively assessed overweight and obesity (OR = 1.30; p < 0.05) had a better chance of getting advice on diets.
People in the age groups 30-39 years and 40-49 years (OR = 1.71; p < 0.05 and OR = 1.58; p < 0.05), widowed (OR = 2.94; p < 0.05), with two chronic diseases or three and more chronic diseases (OR = 1.92; p < 0.01 and OR = 3.89; p < 0.001), and subjectively assessed overweight and obesity (OR = 1.61; p < 0.01) had a better chance of getting advice on physical activity. Gender, education, marital status, professional situation, and diseases occurring in the family in the multivariate logistic regression analysis did not increase the chance of getting advice on diet or physical activity.

Body Weight Measurement
Among the respondents, 9.6% of individuals indicated that their body weight was measured using a scale by a GP once a year. Once a year, height was measured in 11.6% of the patients, and waist circumference was measured in 3.8% of the subjects. Forty two percent of the respondents indicated that body weight was measured in case of clinical indications, similarly to height and waist circumference (Table 4).
According to the respondents, the body mass index was calculated by a physician mainly in the case of clinical indications (25.3%). Moreover, 7.3% of the respondents reported BMI measurement once a year.
In the study group, 2.3% of the obese and 1.3% of the overweight subjects were prescribed medication for weight loss, whereas 1.1% of the obese and 0.4% of the overweight individuals were referred for obesity surgery.

Discussion
The issue of overweight and obesity is rarely discussed in GPs' practices. Our crosssectional study is one of the first in Poland to take up the topic of the nutritional and physical activity counseling provided by family doctors in primary health care during the COVID-19 pandemic. Every third person who joined our study admitted to having received advice on nutrition and physical activity from their GP. Obese patients were advised more often than overweight patients.
However, this counseling was only offered sometimes, not with every routine visit to the GP. Our data do not differ from other studies which show that GPs do not counsel their overweight patients or provide a low level of counseling [21,[32][33][34][35][36].
However, the frequency of advice given to obese and overweight people in our study can be considered higher than that reported in other studies, although it cannot be considered satisfactory. In other studies, the frequency of diagnosing overweight in patients by primary care physicians is low [37].
The results of research in Germany [38], France [39], and Hungary [40] showed that most GPs underestimated the prevalence of overweight, considering it as a norm.
A decline in the popularity of counseling related to weight loss and physical activity was also noted in American and German studies [41][42][43]. Obesity is also insufficiently controlled by GPs, as shown by the data from the United Kingdom [24,44]. Less than half of obese patients seeking medical attention have been recommended by their GPs to lose weight or take up physical activity [45][46][47].
In some studies, the advice on exercise and nutrition was fairly general, without giving detailed strategies [48,49]. Similarly, in our study, the advice given to patients was mainly related to general tips on changing diet, exercise, or weight loss. However, our study found that detailed advice on diet/nutrition and exercise was also given. GPs recommended specific nutrients and foods or eating behaviors, as in other studies [50][51][52].
A doctor's advice can help patients achieve positive behavioral changes and promote weight loss efforts [53].
Motivating patients to take responsibility for their health should be the main objective of GP consultation in the treatment of obesity [54]. A lack of patient motivation is the main barrier to the effective management of the problem in primary care [54]. Motivational interviewing (MI) can improve weight attitudes and behavior and thus lead to improved weight loss [55,56]. There was a correlation between the advice received and the patient's attempt to lose weight [57].
Research shows that MI increases weight loss in overweight and obese people as compared to those who were not provided with such an intervention [55,56].
The low percentage of advice on diet and exercise reported by overweight patients suggests that more lifestyle advice should be offered in primary care [57]. It is important to adapt counseling to the individual needs of each patient [58].
The results of our study show that discussions about nutrition and physical activity were more often undertaken by GPs than by patients. Similarly, in other studies, GPs were more likely to initiate most weight discussions than patients [22], and they also measured body weight [59].
Patients prefer to receive weight management support from GPs rather than other health care professionals [23].
However, some patients have little confidence in their GP regarding obesity management and do not feel sufficiently supported in their weight control [60,61]. Research shows that some patients consider it to be their own (not their doctor's) responsibility to control their weight [62].
Our study reported a low percentage of patient's body weight, height, and waist measurements performed by GPs. Australian and German studies also showed that routine body weight measurements were rare [63]. Such measurements should be an integral part of the physical examination for overweight and obesity and should be performed at least annually [5]. It is obligatory during the first visit to the family doctor to have the patient's weight, height, and waist circumference measured.
Our study found that the likelihood of being provided with counseling was related to BMI. GPs were more likely to give advice when the BMI was high, as in other studies [57].
The obesity management guidelines of the National Institute for Health and Care Excellence (NICE) focus on the concept of patient-centered care, advising that the choice of weight management interventions should be discussed and agreed upon with each individual patient [64]. Polish and foreign guidelines recommend a routine identification of obesity in primary health care, using BMI (body mass index) as a practical assessment of obesity in adults [25,64,65].
Our study found that as age and comorbidities increased, so did the percentage of people advised by GPs. Similarly, in other studies, physicians were more likely to provide weight management counseling to patients with comorbidities, including those related to obesity, than to overweight and obese patients without risk factors [66,67].
Overweight and obesity are rarely treated as a single disease, most often being managed in combination with other diseases such as cardiovascular disease [54].
Our study found that GPs' advice for overweight patients depended on the patient's socio-demographic characteristics. The subjects aged 30-39 and 40-49 years and the widowed patients were more likely to receive advice on physical activity. In the Swedish study, men, younger, and better-educated patients were consulted more often by their family doctor [21]. Other authors have shown that a higher percentage of women and older people received counseling [36].
The most common barrier related to the poor counseling mentioned by doctors and patients is the time limit of the medical appointment for each patient [47,63]. A successful intervention and follow-up of the patient require time. Due to the short visiting times, comprehensive lifestyle recommendations may not be practicable.
Some GPs argue that primary care is not an appropriate resource for intervention and that patients are responsible for their obesity [68,69]. Many doctors indicate a lack of motivation to change patients' behavior and a lack of self-efficacy [45,54,68,70,71].
It has been shown that coordination between primary and specialist health care for obese patients is poorly developed [72]. Advice that suggests dietary modification and increased physical activity is given more often than referrals [73]. This was also confirmed by our study, in which a small percentage of overweight and obese respondents were referred by their family doctor to another health specialist.
The current literature shows that GPs are essential for engaging patients in interventions aimed at reducing their overweight and obesity [63].
The strengths and limitations of the study are as follows. This is the latest study on the impact of a family doctor on the health behaviors of overweight and obese patients in Poland conducted during the COVID-19 pandemic. There are not many studies on this issue in Poland, and it is the first such study to provide information on the scale of counseling provided during the COVID-19 pandemic.
This study describes the urban population which ensures the generalization of the results for other urban areas and other populations. The advantage of this study is the examination of many determinants that may influence the counseling of family doctors among the studied population.
This study also has limitations. It was cross-sectional and carried out over a single time point, which makes it impossible to observe changes over longer periods. To obtain health benefits, a several-month intervention is insufficient; instead, an intervention must be carried out over a long-term.
This study was also limited by the study period during the COVID-19 pandemic. It was associated with difficult access to patients, and not all patients visited their family doctor in this period.
Nutrition and physical activity counseling by GPs were assessed using patient selfreported questionnaire data, which may be associated with recall bias.
The questionnaire did not include a question on the reason for which the patient came to the doctor; however, regardless of the cause, the family doctor should always notice overweight and obesity and encourage the patient to start treatment.
The lack of association in multivariate analyses may be caused by the small sample size. Moreover, in the current study, we have evaluated the patient-related variables (socio-demographic or health related factors). However, the other variables, including doctor-related ones, which were not evaluated in the present study, may be more important correlates of counseling provided by primary care physicians.
Additionally, the results of the research may be important for the development of health programs aimed at reducing overweight and obesity in Poland and other countries.
Our study was anonymous, and thus the respondents could not be linked to their GPs in any way.

Conclusions
The study identified correlates of higher counseling for overweight and obesity-related chronic diseases. The percentage of advice in Poland on diet and physical activity from primary care physicians reported by overweight and obese patients remains low.
The study found a higher proportion of advice on diet and physical activity provided by primary care physicians to overweight and obese patients than in other studies; however, still not all patients receive the necessary counseling.
Primary care physicians should advise all patients not to be overweight and obese, not only those already affected by the problem. The study shows that primary care physicians focus on the treatment of overweight and obesity, but not its prevention. Early prophylaxis is important as it ensures more benefits for the patient than a modification of the treatment. Family doctors should raise awareness and shape the pro-health attitudes of their patients.
Counseling appears to have a significant impact on changing the health behaviors related to weight control among patients, which is a priority for improving the health of the population. It is important to study the work of doctors in the field of overweight and obesity counseling. There is a need for additional efforts to increase the frequency of the abovementioned advice in primary care. Determining the importance of primary health care counseling by the National Health Fund will be helpful in this respect. When planning prevention programs, healthcare managers in Lodz and other cities in Poland should consider counseling as a part of the regular primary healthcare services.