The knowledge and practices of physicians regarding pharmacotherapy of obesity the current scenario in pakistan

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ISSN Print: 2278 – 2648 IJRPP | Vol - 3 | Issue 1 | Jan-Mar-2014
ISSN Online: 2278-2656 Journal Home page: www.ijrpp.com
Review article Open Access
The Knowledge and Practices of Physicians Regarding Pharmacotherapy
of Obesity: The Current Scenario in Pakistan
Sadaf Shahid1
, Atta Abbas1,2
*, Arif Sabah1
, Sidra Tanwir1
, Farrukh Rafiq Ahmed1
,
Shazia Adnan1
and Syed Imran Ali1
1
Faculty of Pharmacy, Ziauddin University, Karachi, Sindh, Pakistan.
2
Department of Pharmacy Health and Well Being, University of Sunderland, England,
United Kingdom.
* Corresponding author: Atta Abbas
E-mail id: bg33bd@student.sunderland.ac.uk
Abstract
Obesity in Pakistan has been largely underestimated in terms of prevalence. It is becoming an increasingly important
public health issue as it relates to a number of non-communicable and chronic diseases. It is suggested that safe and
effective pharmacotherapy along with the usual interventions by physicians can benefit in reducing overweight or
obese status in patients. The discrepancies and consistencies of practices among physicians for managing obesity
using pharmacotherapy in different settings and situations have been assessed, along with comparisons between
problems of medical education of Pakistan that can affect decisions to use pharmacotherapy for management of
obesity. It has been suggested that the prospect for upgraded information or knowledge regarding pharmacotherapy
to manage obesity depends on hands on training, learning, and improving of medical education for physicians all
over Pakistan along with pharmacist physician collaboration which can help decrease the burden of this disease and
can reduce the considerable morbidity and mortality as remedy of such a crisis.
Keywords: Knowledge; Physicians; Pharmacotherapy; Obesity; Pakistan.
INTRODUCTION
There are certain medical conditions that need safe
and effective therapy by achieving reduction of
symptomatology, as well as elimination or reduction
of a patients’ ailments.1
Obesity is a disease that can
lead to complications of the heart, the
musculoskeletal system, endocrinology and other
systems. Pharmacotherapy is a desirable choice for
treatment of medical conditions such as obesity that
affect quality of life and/or threaten mortality which
can spare suffering for many individuals.2
This can be
stressed upon due to abundant evidence collected
from epidemiological and interventional studies
which suggest that morbidity from diabetes,
cardiovascular disease, cerebrovascular disease,
osteoarthritis, sleep apnea, would all be reduced in
proportion to reduction in body fat content.2
Therefore, there is preferably no other medical
condition for which effective and safe
pharmacotherapy is desired than obesity.2
International Journal of Research in
Pharmacology & Pharmacotherapeutics

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The pathogenesis of obesity is very complex, and
mechanisms linking obesity to various diseases are
poorly understood.3
A number of studies suggest that
obesity decreases individual healthy activity,
promotes disability and shortens life span3
. Much
attention has been focused on diet and exercise for
management of obesity, but these strategies alone are
not effective in maintaining weight loss and obesity
prevention3
. To overcome these complications caused
by obesity, physicians must understand the
pathogenesis of obesity and emphasize on other
options that are effective in treating obesity3
.
The National Health Survey data set clearly shows
the double burden of malnutrition and over-weight in
adolescents and adults. Adolescents in Pakistan are
underweight rather than overweight4
, while the vice
versa is true for adults, therefore developing
countries like Pakistan may experience a larger
burden of obese individuals in the next few decades4
.
In South Asia, including Pakistan, the coexistence of
underweight in early life with obesity in adults may
presage both a higher prevalence and incidence for
non-communicable diseases (NCDs) such as
hypertension and diabetes5
.
Pakistani physicians are realistic about treatment
outcomes of threatening non-communicable diseases
(NCDS), for instance, Primary care physicians
regularly doing follow-up at diabetic clinics have
much better knowledge overall, about nutrition-
related questions and target blood glucose levels for
optimal control as a basic practice23
, although to
which extent needs to be further assessed in case of
obesity.
Misperception in terms of prevalence in overweight
and obese status is high in Pakistani population.6
Underestimation of weight status contributes to the
denial of the current weight being a health risk and
contributes to increase in health problems associated
with obesity.6
The prevalence of overweight and
obesity and their association with hypertension and
diabetes mellitus reported that 25 % of adult
population in Pakistan is overweight or obese, based
on re-analysis of National Health Survey 1990-1994
by using BMI criteria. The prevalence is higher in
urban areas, affecting one third of men and nearly
half the women.7
In cities, there is more access to
food and sedentary life style. Rising urbanization is
one of the contributing factors to the crisis. The
tendency to gain weight runs in families and certain
ethnic groups. Many family members not only are
genetically predisposed but diet and habits may
contribute to obesity.7
In Pakistan 55.12% among
males and 36.15% among females are either
overweight or obese, also married people are three
times as obese as compared to unmarried ones.8
Developing countries like Pakistan are increasingly
exposed to conditions sometimes labeled “diseases of
affluence” while struggling to control their
continuing problems of malnutrition and infectious
diseases associated with underdevelopment.9
The
health status of Pakistani population comparable with
that to the United States observed that in the US
population, prevalence rates decrease from groups of
low to high status for hypertension, obesity, high
cholesterol, and smoking. In Pakistan, the gradients
run in the other direction (except for smoking), with
higher levels of cardiovascular risk factors found in
economically better-off portions of the population.9
Also adolescents in high schools of Pakistan were
found to be more overweight compared to
underweight students.10
Therefore, with all the
nutrition transition, urbanization, dietary patterns,
social, economic, demographical and recent health
status, Pakistan will experience a burden of this
disease in the next few decades.4
DISCUSSION
With the recent establishment of obesity prevalence
in Pakistan, the question arises on the attitudes of
practicing Pakistani physicians on how they would
prefer to manage this disease. There are various
methods to choose from, most popular form of
treatment undertaken by any practicing physician is
to start with the non-pharmacotherapy and then
pharmacotherapy or together.
A number of studies assessing the physician’s
response to the demise of obesity in terms of their
knowledge and health awareness have been
conducted in several countries. In no chronological
order, primary healthcare physicians regarding
obesity management in Israel revealed that 60% had
insufficient knowledge and a vast majority were

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unaware of the drug prescription’s indications.11
similarly in France most of the GP under estimated
the prevalence of obesity, only 6.7% were aware of
the guidelines for obesity management, and 80%
acknowledged they needed more training in this
field.12
Australian physicians although they
considered themselves to be well prepared to treat
over weight patients, they believed that they had
limited efficacy in weight management and found it
professionally unrewarding. Their approaches were
least likely to be considered important and/or least
likely to be practiced.13
The fear of limited
knowledge regarding management of obesity were
also found among physicians in Kuwait.14
In the Swiss survey15
, more than half of the
physicians felt confident in managing obesity, the
only flaw was half of the GP’s seldom performed
weight management and documentation.15
Likewise
in Great Britain, lack of professional satisfaction
when counseling for obesity were identified. Their
training at medical school and by postgraduate
courses were the least important sources of
knowledge. In the nutrition teaching in medical
schools of England, the amount of time devoted to
any nutritional topic in the preclinical years is very
limited and that picture in postgraduate centers are
even worse. The doctors' knowledge of the
prevalence of obesity and weight problems and of
specific dietary recommendations were found poor.16
In New York and Philadelphia, resident physicians
did not feel competent in treating obesity.17
More
than one study of for attitudes of physicians
regarding obesity management were conducted all
over USA revealing almost similar findings. And
lastly physicians in Bahrain revealed that the
majority of physicians (92%) were aware of the
obesity epidemic and almost half (60%) of them felt
capable of assuming a major role in obesity control,
reporting a high rate of utilization of various weight
loss strategies, except for pharmacotherapy and
surgery, suggesting Bahraini physicians to be
supported with appropriate training.18
Physicians in these different study populations all
over the world generally lack the will to treat obesity
with complete satisfaction providing all necessary
guidelines, the pharmacotherapy is pushed behind as
a last or a no option in the management of this
disease, whereas incomplete sets of knowledge
becomes their hurdle in making appropriate medical
decisions in this particular disease. 19
The question however is that how near or far is the
medical education or training in Pakistan with the
similar situations as faced by the countries mentioned
above on choosing pharmacotherapy for management
of obesity.
There is a large evidence base regarding the success
of treating obesity with some specified
pharmacological agents. The use of orlistat in the
long term treatment of obesity in primary care
settings acts as an effective adjunct to dietary
intervention in management of obesity.20
A group of
scientists and physicians performed a randomized
trial of life style modification and pharmacotherapy
of obesity, published in the New England Journal of
Medicine(NEJM), which reveals that the combination
of medication and group lifestyle modification results
in more weight loss than either medication or
lifestyle modification alone.21
The effectiveness of sibutramine, orlistat and
isphagula in Pakistani obese patients reveals that all
the three drugs were effective in losing weight but
sibutramine is more effective in losing weight and
total body fat content as compared to ispaghula and
orlistat among patients.22
Therefore evidences from
both international and local studies, employment of
pharmacotherapy is the right choice along with other
interventions.
But would pharmacotherapy have existed as a choice
in the knowledge sets of a practicing Pakistani
physician? To determine the knowledge sets of a
Pakistani physician, it would require determining the
exact standards and barriers of medical education in
Pakistan, pre-clinical, post graduate, or other. Obesity
leads to type 2 diabetes mellitus1
, the comorbid
condition itself has little attention i.e. demanding
further education23
, it is rather appalling to interpret
the amount of attention focused by the them on the
cause itself i.e., obesity.
Prescribing practices of consultant physicians in
Pakistan are rather liberal and not rational when it
comes to prescribing medicines. Mostly in the case of
antimicrobials and vitamins. 1

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The relationship between the hesitation to advise
pharmacotherapy and updated knowledge sets is
assessed in a review that observed on the reasons as
to why physicians do not follow clinical guidelines24
in which barriers to physician adherence to practice
guidelines are compared in relation to behavioral
change, the sequence of behavior change first begins
with knowledge. Due to external, environmental or
presence of contradictory guidelines factors,
physicians first experience lack of familiarity and
lack of awareness (due to volume of information,
time needed to stay informed, and guideline
accessibility) these coming under the umbrella of
knowledge in turn affect physician’s attitudes, which
can cause them to experience one or more than the
one of the following conditions specified below 24
:
Lack of agreement with specific guidelines
(interpretation of evidence, applicability to patient,
not cost beneficial, lack of confidence in guideline
developer), lack of agreement of guidelines in
general (“too cookbook”, too rigid to apply, biased
synthesis, change to autonomy, not practical), lack of
outcome expectancy (physician believes that
performance of guideline recommendation will not
lead to desired outcome), lack of self-efficacy
(physician believes that he or she cannot perform
guideline recommendation) 24
and lack of motivation
(inertia of previous practice, habit and routines).24
The environmental causes leading to these certain
physician attitudes are lack of time, lack of resources
organizational constraints, lack of reimbursement,
perceived increase in malpractice liability.24
One of many problems facing the medical education
in Pakistan are that since its inception medical
education in Pakistan witnessed very little or no
change at all.25
. There are raised concerns on present
medical education at various forums. Although,
Pakistan Medical and Dental Council (PMDC) had
chalked out the outlines of the medical curriculum,
yet the irony of fact noted is that most of the faculty
members involved in teaching are not aware of its
existence25
. Hence, teaching is carried out
accordingly. Moreover, the course outlines are found
vague, not clearly defined, resulting in the ambiguity
of the situation. Therefore yesterday’s programs are a
misfit for today’s problems25
a few attempts have
been made to revise the existing curriculum but are
not successful in bringing any substantial change.
There is no standardized ready to use curriculum that
can be adopted.25
Therefore under such situations,
Pakistan needs improvement and attention just like
the other countries facing a similar situation in
requisite of a proper disease management.25
The need for continuing medical education for
Pakistan has been stressed, a framework for planning
and structured continuous professional development
program is proposed identifying various issues that
need to be addressed in the planning and
implementation26
. The professional development of
doctors is a life- long commitment, which has been
considered an obligation on the part of practicing
doctor’s right from early times. Many countries
worldwide have made major changes in their
organizational set up to provide doctors with ample
opportunities to develop professionally. However, in
Pakistan, where once qualified and registered, the
doctor is licensed to practice for life26
. There are a
number of solutions that can fill appropriate
knowledge gaps facing our country’s health care
practitioners regarding obesity management with
pharmacotherapy, there are two major guidelines
published for the management of adult and child
obesity, the 2006 Canadian clinical practice
guidelines on the management and prevention of
obesity in adults and children27
, and the Management
of Obesity in Adults: European Clinical Practice
Guidelines 28
, these are few authentic guidelines that
highlight a step wise approach in management of
obesity. A simple revision or updating of knowledge
by going through yearly publications and guidelines
requires time and effort, a document published by the
Royal College of Physicians in March 2010
regarding the training of health professionals for the
prevention and treatment of overweight and obesity29
which provides a framework for training and
education of health care professionals regarding
overweight and obesity as preregistration training and
post registration training as well as training programs
during practice. Some of these training programs
include formative assessments to evaluate how well
knowledge and competence are maintained through
practice. The Intercollegiate Group on Nutrition of

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the Academy of Medical Royal Colleges runs an
Intercollegiate Course in Human Nutrition29
that
fulfils the prescribed learning needs.29
Some medical
organizations have been critical of an expanded role
for pharmacists in primary health care, opposing
pharmacy as the first point of call for treating minor
ailments.32
The roles of the doctor and pharmacist are
complementary. Good working relationships between
all healthcare professionals are essential to the
delivery of personalized and effective patient
services. As all health professions must show greater
responsiveness to changing patient needs. 32, 33
CONCLUSION
Similar training programs and assessments should be
conducted throughout Pakistan, in medical colleges
and in post graduate training programs, in which
advising pharmacotherapy of obesity is made a
mandatory clinical practice to help overcome this
disease epidemic. Online learning should be made a
regular practice; it can help increase professionals'
knowledge, skills, and self-efficacy about nutrition
to prevent obesity 30
The burden of physicians should be divided, the
intervention of a pharmacist in lieu of a physician can
help reduce the environmental burden and barriers as
discussed above in problems faced by practitioners in
Pakistan, this can save time and more time can be
focused on upgrading prescribing and practicing
skills. Teamwork, communication and collaboration
between health professionals are important for the
safe and effective delivery of health care.
Pharmacists have the skills and knowledge to
contribute to the quality use of medicines, to
minimize medication misadventure and to help
consumers better manage their medicines.
Interdisciplinary clinical teaching, communication
and relationships are the keys to improving
collaboration to achieve optimal medication
management and addressing healthcare needs of the
society. Knowledge can be exchanged by inter
professional collaboration between general
practitioners and pharmacists, therefore the
recognition of a pharmacist’s role in disease
management along with knowledge up gradation can
accelerate the successful eradication of diseases that
has affected the nation on a mass scale.31, 32,33
REFERENCES
[1] N. Das H. Baloch. Prescribing Practices of Consultants at Karachi, Pakistan. 2006. JPMA 51:74.
[2] David S. Weigle .Pharmacological Therapy of Obesity: Past, Present, and Future. 2003. The Journal of.
Clinical Endocrinology & Metabolism. 88(6): 2462–2469 P.
[3] Rexford S. Ahima. Digging deeper into obesity. 2013. The Journal of Clinical Investigation. 2076-2079 P.
[4] Bharmal FY. Trends in Nutrition Transition: Pakistan in focus. 2000. J Pak Med Assoc. 50:159-67 P.
[5] National health survey of Pakistan 1990-94: health profile of the people of Pakistan Islamabad: 1997.
PMRC. 181 P.
[6] S Bhanji, A K Khuwaja, F Siddiqui, I Azam and K Kazmi. Underestimation of weight and its associated
factors among overweight and obese adults in Pakistan: a cross sectional study. 2011. Biomed central
BMC Public Health. 11:363.
[7] M H Khan, H Khan, G Sarwar, B Iftikhar, A Jan, M Naimat-ullah, A Gul. Study of Obese Persons Profile
at D.I. Khan, NWFP, Pakistan. 2008. Gomal Journal of Medical Sciences. 6(2): 77-80 P.
[8] M Aslam, A Saeed, G.R. Pasha and S Altaf .Gender Differences of Body Mass Index in Adults of
Pakistan: A Case Study of Multan City. 2010. Pakistan Journal of Nutrition. 9(2): 162-166 P.
[9] G Pappas, T Akhtar, P J. Gergen, W C. Hadden, and A Q Khan. Health Status of the Pakistani Population:
A Health Profile and Comparison with the United States. 2001. American Journal of Public Health.
91(1):93-98 P.
[10] T.Rehman, Z. Rizvi, U. Siddiqui, S Ahmad, A. Sophie, M. Siddiqui, O. Saeed, Q. Kizilbash, A. Shaikh ,
A. Lakhani, A. Shakoor . Obesity in Adolescents of Pakistan. 2003. JPMA 53:315

6. Atta Abbas et al / Int. J. of Res. in Pharmacology and Pharmacotherapeutics Vol-3(1)2014 [53-59]
www.ijrpp.com
~ 58~
[11] Y Fogelman, S Vinker, J Lachter, A. Biderman, B Itzhak and E Kitai. Managing obesity: a survey of
attitudes and practices among Israeli primary care physicians. 2002. International Journal of Obesity 26,
1393-1397.
[12] Aure´lie Bocquier, Pierre Verger, Arnaud Basdevant, Ge´rard Andreotti, Jean Baretge, Patrick Villani,
and Alain Paraponaris. Overweight and Obesity: Knowledge, Attitudes, and Practices of General
Practitioners in France. 2005. Obesity Research. 13(4): 787-795 P.
[13] K Campbell, H Engel, A. Timperio, C Cooper, and D Crawford. Obesity Management: Australian
General Practitioners’ Attitudes and Practices. 2000. Obesity research. 8(6): 459-466 P.
[14] Anwar A. Al-Najjar, Najlah J.M. Al-Jasem, Yasmeen F. Al-Quraini, Osama Salama and Medhat K. El-
Shazly. Knowledge and attitude of primary health care doctors towards obesity management, Kuwait.
2012. Greener Journal of Medical Sciences. 2(5): 120-129 P.
[15] CA Huber, M Mohler-Kuo, U Zellweger, M Zoller, T Rosemann and Ol Senn. Obesity management and
continuing medical education in primary care: results of a Swiss survey. 2011. Biomed central BMC
Public Health. 12:140.
[16] Janet Cade, Shaun O' Connell. Management of weight problems and obesity: knowledge, attitudes and
current practice of general practitioners. 1991. British Journal of General Practice, 41: 147-150 P.
[17] N J. Davis, H Shishodia, B Taqui, C Dumfeh, J W-Rosett. Resident Physician Attitudes and Competence
about Obesity Treatment: Need for Improved Education. 2007. Med Educ Online. 13:5
[18] Abeer Al-Ghawi, Ricardo Uauy. Study of the knowledge, attitudes and practices of physicians towards
obesity management in primary health care in Bahrain. 2009. Public Health Nutrition: 12(10): 1791–1798
P.
[19] Rebecca M. Puhl and Chelsea A. Heuer. The Stigma of Obesity: A Review and Update.2009. Obesity 17:
41–964 P.
[20] J Hauptman, C Lucas, M N. Boldrin, H Collins, K R. Segal, Orlistat in the Long-term Treatment of
Obesity in Primary Care Settings. 2002. Arch Fam Med. 9:160-167 P.
[21] T A. Wadden, R I. Berkowitz, M.D., Leslie G. Womble, David B. Sarwer, S Phelan. Randomized Trial of
Lifestyle Modification and Pharmacotherapy for Obesity. 2005. N Engl J Med. 353: 2111-20 P.
[22] Syed J Kazmi, M Khan, Ghulam Rasool Mashori, A. Saleem, N Akhtar, A Jahangeer. Influence of
Sibutramine, Orlistat and Isphagula in Reducing body weight and total Body Fat Content in Obese
Individuals. 2009. J Ayub Med Coll Abbottabad. 21(2) 45-48 P.
[23] A. S. Shera,F. Jawad .Diabetes related Knowledge, Attitude and Practices of Family Physicians in
Pakistan. 2002. JPMA. 52:465 P.
[24] Michael D. Cabana. Why Don’t Physicians Follow Clinical Practice Guidelines? A Framework for
Improvement. 1999. JAMA. 282(15): 1456-1465 P.
[25]Arshia Samin Naqvi .Problems of Medical Education in Pakistan. 1997. JPMA 47:267 267-269 P.
[26]Z. S. Siddiqui, M J. Secombe, R. Peterson. Continuous Professional Development - Development of a
Framework for Medical Doctors in Pakistan. 2003. JPMA 53:290 P.
[27] Canadian clinical practice guidelines on the management and prevention of obesity in adults and children,
2007. 176(8): CMAJ. 176(8 suppl): 1–117 P.
[28] C Tsigos V Hainer. Management of Obesity in Adults: European Clinical Practice Guidelines. 2008.
Obesity Facts The European Journal of Obesity. 1:106–116 P.
[29]RCP London . [Report]. The training of health professionals for the prevention and treatment of
overweight and obesity. 2010 Report: Foresight by the Royal College of Physicians
[30]Christina M. Stark. Online Course Increases Nutrition Professionals' Knowledge, Skills, and Self-Efficacy
in Using an Ecological Approach to Prevent Childhood. 2011. Obesity Journal of Nutrition Education and
Behavior 43(5): 316–322 P.

7. Atta Abbas et al / Int. J. of Res. in Pharmacology and Pharmacotherapeutics Vol-3(1)2014 [53-59]
www.ijrpp.com
~ 59~
[31]Thomas E. Menighan .More pharmacist/physician collaboration, not less. 2013. American Pharmacists
Association online CEO Blog. June 21 2013
[32]Debbie Rigby. Collaboration between doctors and pharmacists in the community. 2010. Aust Prescr.
33:191-3 P.
[33]Syed Ata Rizvi, Sadaf Shahid, Atta Abbas, Sidra Tanwir, Shazia Adnan, Arif Sabah, Wafa Saghir, Khizar
Jabbar, Asma Qadri and Amna Bibi. Knowledge, experience and perception of physicians regarding
pharmacotherapy of obesity: a survey of Pakistan. 2014. Inter. J. of Pharmacotherapy. 4(2): 80-85 P