Knowledge and Perception of Bariatric Surgery among Physicians at King Saud University Medical City, Riyadh, Saudi Arabia

Wael Saleh Almogheer^*, Ayan Ahmed Hassan and Ahlam F Alotaibi

^*Correspondence: Wael Saleh Almogheer, Department of Family and Community Medicine, College of Medicine, King Saud University Medical City, King saud university, Saudi Arabia, Email:

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Introduction

Obesity has become one of the most common and chronic nutritional problems worldwide. It tends to impact more than one third of the population and result in 5% of all deaths globally [1, 2]. In Saudi Arabia, it was reported that 24.1% of the females and 33.5% of the males are obese, while the prevalence of overweight among males and females was 33.4% and 28.0% respectively, according to Saudi Health Interview Survey [3].

Obesity-related comorbidities including type 2 diabetes, hyperlipidemia, hypertension, asthma, obstructive sleep apnea, hypertrophic cardiomyopathy, cholelithiasis, and psychosocial impairment have been studied extensively [4]. The 2002 World Health report estimated that >2.5 million deaths every year were due to weight-related comorbidities [5]. As a consequent, a wide range of physicians at different specialties expose to patients with obesity and obesity-related comorbidities in everyday clinical practice [6].

It has been shown that sustained weight reduction is strongly related with the prevention, improvement, and resolution of these detrimental health effects [7]. Studies have demonstrated that traditional dieting attempts and lifestyle modifications often fail to achieve long-lasting results in patients with morbid obesity [8]. The role of pharmaceutical therapy in treating obesity is relatively ineffective; however, bariatric surgery has emerged as the most effective and currently available treatment in obese patient populations. Most patients with obesityrelated comorbidities lose an average of 30 kg after undergoing bariatric surgery and experience complete health resolution or improvement in the long-term [9].

Although medical physicians acknowledge the advantages of bariatric surgery for patients who are eligible for surgery, it is still sporadically suggested, and the number of those morbidly obese patients is inconsistent with their referral percentages [10-13]. The American Society for Metabolic and Bariatric Surgery and the Estimate of Bariatric Surgery Numbers estimated that less than 1% of American obese patients who are qualified for bariatric surgery underwent surgery between 2011-2017 [14-17]. Reasons for the low referral rates and the barriers influencing the use of bariatric surgery are of manifolds [17]. In spite of the importance role of bariatric surgery in the management of chronic diseases among physicians, no local nor regional studies have been found. The aim of this study is to identify the level of perception among physicians working in King Saud University Medical City (KSUMC) about the role of bariatric surgery in their management of obesity and to identify factors that influence referral patterns. We also aim to discover their interest in learning more about bariatric surgery.

Results from this study could be used to inform the service in KSUMC and other hospitals in Saudi Arabia in order to improve referral to bariatric surgery as an effective treatment for selected obese patients.

Methodology

This study is a single-cantered, cross-sectional study that was conducted at King Saud university medical city (KSUMC), Riyadh, Saudi Arabia during December 2020 to March 2021. KSUMC is a tertiary care centre in Riyadh, Saudi Arabia. The study population included doctors with varying medical specialties. All physicians (consultant, fellows, and registrars) at King Saud university medical city were included, and they were 201 physicians. Inclusion criteria were family physicians, internist physicians, obstetrics and gynaecology physicians, general surgery physicians, and orthopaedic physicians who work under the KSUMC. Exclusion criteria were physicians from other specialties. The study assess the knowledge and perception of bariatric surgery among physicians at king Saud university medical city using a pre designed validated questionnaire developed.

The questionnaire was self-administered, online based; copyright permission was obtained through email. The survey consists of 27 questions intended to assess the perception toward treatment and management of bariatric patients, overall knowledge regarding benefits of bariatric surgery, and awareness of institutional resources available for these patients.

An electronic copy of the survey was developed using survey by Google form and distributed to all King Saud University Medical City (KSUMC) physicians with an email address. A total of 201 physicians were invited to complete the survey.

The included variables were the age, gender, previous referrals, level, years in practice, and specialty. The protocol for this research project was approved by the Institutional Review Board (IRB).

The demographic characteristics and responses between physicians who had made previous referrals for surgery versus those with no history of referral were compared using univariate analysis. Data were described in this study as frequencies and percentages. The associations between independent and dependent variables were tested by chi square test and Fisher exact test as appropriate. The significance level for all group comparisons was set at a p value <0.05. Statistical analysis was conducted using IBM SPSS Statistics 24 (IBM Corp., Armonk, NY).

Results

The present study sought to identify the level of perception among physicians working in King Saud University Medical City (KSUMC) about the role of bariatric surgery in their management of obesity and to identify factors that influence referral patterns. A total of 127 physicians were enrolled in the present study. This section provides an overview of the study findings related to study variables and parameters.

The findings shown in Table 1 represent the demographic characteristics of the physicians enrolled in this study. As shown in Table 1, physicians who were aged 26 to 35 years constituted 36.2% (n=46) of the study participants, followed by the physicians who were 36 to 45 years old (31.5%, n=40). The least represented age category was physicians aged 66 to 75 as there was only one physician (0.8%).

Table 1: Demographic characteristics of physicians enrolled.

Categorizing the participating physicians based on their gender revealed that males constituted 57.5% (n=73), whereas females were constituting 42.5% (n=54) of the recruited study sample.

In terms of years of practice, it was found that physicians who had an experience of 6 to 10 years constituted 29.9% (n=38), while physicians whose years of experience ranged from 11 to 15 years were ranked second (18.1%, n=23). The least represented category were those physicians who had 21 to 25 years of experience as they constituted 7.9% (n=10).

Moreover, it was found that family medicine physicians constituted 30.7% (n=39), whereas internal medicine physicians and obstetrics and gynaecology physicians constituted 27.6% (n=35) and 17.3% (n=22), respectively. In addition, the results showed that the orthopaedic physicians were constituting 15.7% (n=20), while general surgery physicians were the lowest represented category among the study participants (8.7%, n=11).

Exploring the level of the participating physicians revealed that consultants were 63.9% (n=81), whereas fellows and registrars were constituting 26.8% (n=34) and 9.4% (n=12), respectively.

Finally, it was found that 62.2% (n=79) of the enrolled physicians had a weekly patient load of 26 to 50 patients, whereas 18.9% (n=24) had less than 25 patients weekly. In addition, 13.4% (n=17) had a weekly patient load of 51 to 100 patients. However, only 5.5% (n=7) of the enrolled physicians had a weekly patient load of more than 100 patients.

As shown in Table 2, about 90.6% (n=115) of the enrolled physicians reported that they measure the patient’s weight each visit, whereas only 3.9% (n=5) were used to measure their patient’s weight every year and 5.5% (n=7) reported that they never measured patient’s weight. The BMI measurement was used as an additional measurement by 95.3% (n=121), whereas waist circumference was used by 4.7% (n=6) of the enrolled physicians.

Table 2: Physician’s management of obese patients.

The findings of this study showed that about 57.5% (n=73) of the enrolled physicians initiate conversation with patients about bariatric surgery, while 25.2% (n=32) sometimes initiate this type of conversation and 17.3% (n=22) do not initiate any conversation related to bariatric surgery with their patients.

Moreover, the results showed that 70% (n=89) had an access to appropriate resources and equipment for managing morbidly obese patients. The results showed that 67.7% (n=86) of the enrolled physicians had sufficient of knowledge of who to contact if having difficulty managing patients with morbid obesity. Moreover, it was found that 88.1% (n=111) referred patients to bariatric surgery before.

The findings showed that 32.3% (n=41) of the enrolled physicians had 6 to 10 patients who have had bariatric procedures before, whereas 29.1% (n=37) had more than 20 patients who have had bariatric procedure before and 22.8% (n=29) had one to five patients who have had bariatric surgery before.

About 44.9% (n=57) of the enrolled physicians reported that less than 21% of the patients seen in the last 12 months were morbid obese (BMI>35). However, 25.2% (n=32) of the physicians reported that among the patients seen within the last 12 months, about 12 to 30% were morbid obese (BMI>35), and 23.6% (n=30) had 31 to 40% morbid obese patients among the patients seen in the last 12 months.

Exploring the reasons of no referrals to bariatric surgery revealed that lack of resources was the most reported reasons (25%, n=7), whereas lack of awareness about procedure or benefits, concerns with follow up, and psychological issues were the secondly ranked reasons for no referrals (21.4%, n=6). Disagree with procedure was reported as another reason by 17.9% (n=5) of the physicians reporting no referrals.

The results showed that 10.7% (n=3) reported that discomfort within own setup to manage patients is the main reason for no referral for bariatric surgery. However, the same percentage reported that medical issues are their main reason for no referral for bariatric surgery.

The results presented in Table 3 showed that 63% (n=80) of the enrolled physicians believe that Laparoscopic sleeve gastrectomy is the ideal bariatric surgical procedure in the average patients, whereas 10.2% (n=13) reported that the Laparoscopic adjustable gastric band is the ideal bariatric procedure. In addition, about 1.6% (n=2) reported that Laparoscopic Roux-en-Y gastric bypass is the ideal bariatric surgery procedure in the average patients, and only 0.8% (n=1) indicated that Duodenal Switch/Biliopancreatic Diversion is the ideal bariatric surgery procedure in the average patients. Finally, about 24.4% (n=31) of the enrolled physicians were unsure about the idea bariatric surgical procedure in the average patients.

Table 3: Physician’s knowledge of and patient interest in bariatric surgery.

Exploring the patients’ preferences regarding the type of the bariatric surgery from the perspective of the enrolled physicians reported that 63.8% (n=81) of the physicians reported that patients are interested more in Laparoscopic sleeve gastrectomy, whereas 3.1% (n=4) reported that patients are interested more in Laparoscopic Roux-en-Y gastric bypass. In addition, about 22.8% (n=29) of the enrolled physicians reported that patients’ interests regarding the type of the bariatric surgery is not specified, and 3.1% (n=4) of the physicians reported that patients are interested in more than two of the mentioned types of bariatric surgeries. Finally, about 7.1% (n=9) reported that patients never showed an interest in the type of bariatric surgery.

The findings of the current study showed that 39.4% (n=50) reported that less than 10% of the morbid obese patients inquire about bariatric surgery, whereas 27.6% (n=35) reported that 10 to 20% of the morbid obese patients inquire about the bariatric surgery. In addition, it was found that 12.6% (n=16) of the enrolled physicians reported that 21 to 30% of the morbid obese inquire about the bariatric surgery. Moreover, the results revealed that 11% (n=14) of the enrolled physicians reported that more than 40% of the morbid obese patients inquire about the bariatric surgery. Finally, it was found that 9.4% (n=12) of the enrolled physicians reported that 31 to 40% of the morbid obese patients inquire about the bariatric surgery.

The findings of the present study showed that BMI (89.7%, n=113) and comorbidities (82.5%, n=104) were the most factors influencing the decision to refer to bariatric surgery. However, the enrolled physicians reported other reasons such as age (41.3%, n=52), number of attempts at dieting (42.9%, n=54), use of pharmacotherapy for obesity (22.2%, n=28), and patient desire for procedures (35.7%, n=45).

The results shown in Table 4 represent a comparative analysis of the opinions of the enrolled physicians about bariatric surgery in terms of referral or no referral to bariatric surgery. The results showed that 87.9% (n=94) agreed that “morbid obese patients should attempt dieting for at least for 6 months before considering surgery”, 89.2% (n=74) agreed that they “have had morbidly obese patients who were successful at losing weight without surgery”. In addition, the results showed that 97.8% (n=44) of physicians agreed that “bariatric surgeries result in sustained weight loss”. Moreover, about 98.2% (n=56) of the enrolled physicians “felt comfortable explaining the procedural options to a patient” and 97.3% (n=71) “felt comfortable providing care to patients who have received bariatric surgery”. Finally, it was found that 89.2% (n=91) agreed that “additional continuing medical education resources in bariatric surgical care would be useful to physicians in our center”.]

Table 4: Opinions about bariatric surgery: comparison between physicians who have made previous referrals for surgery to those with no previous referrals.

The results presented in Table 5 shows univariate analysis of the perspectives of enrolled physicians based on history of patient’s referral to bariatric surgery. The results revealed that physicians aged 36 to 45 years were 5.7 times more likely to refer patients to bariatric surgery (OR: 5.7, ci: 0.655-49.577, P=0.118). In addition, it was found that physicians who had 11 to 20 years of practice were 1.78 times more likely to patient’s referral to bariatric surgery (OR:1.78, CI: 0.419-7.588). However, the results showed no significant association between physician’s level, specialty and patient load on one hand and referral of morbid obese patients to bariatric surgery on the other hand.]

Table 5: Univariate analysis of the perspectives of physicians based on history of referrals.

The results shown in Table 6 indicated that 59.1% (n=75) of the enrolled physicians reported that the minimum BMI to consider bariatric surgery appropriate for a patient without weight related comorbidities is 40kg/m2, whereas 26.8% (n=34) reported that the minimum BMI is 35 and 5.5% (n=7) believed that a minimum BMI of 30 is the minimum BMI to consider bariatric surgery appropriate for a patient without weight related comorbidities. Moreover, about 5.5% (n=7) believed that a BMI of 45 is the appropriate one, whereas 3.1% (n=4) reported that a BMI higher than 50 is the minimum to consider a patient referral to bariatric surgery.

Table 6: Physicians’ perceptions regarding patient’s referral to bariatric surgery.

The findings revealed that 48% (n=61) of the enrolled physicians were supportive of bariatric surgery for patients with diabetes and BMI<35, whereas 30.7% (n=39) were not supportive. However, 21.3% (n=27) were unsure of bariatric surgery in case of diabetic patients having a BMI less than 35. Finally, it was found that 63% (n=80) reported that they would refer a family member or a friend for gastric bypass surgery.

Discussion

For the severely obese person, the chance of losing and keeping off enough weight to make a health difference (20% excess weight) is in the range of 3% at most [18]. Metabolic and bariatric surgery is indicated for patients who have class III and class IV obesity, a BMI of 40 and over is alone an adequate indication, and it is also indicated for class II obesity; a BMI of 35 to 40 with patients who have certain medical problems, such as hypertension, diabetes, and the chronic diseases that are commonly associated with high morbidity that are also associated with obesity [19].

The present study aimed at investigating the perceptions of Saudi Physicians working in KSUMC about bariatric surgery and its role in obesity management, in addition to identifying the factors influencing the referral of a patient to a bariatric surgery. The findings of the present study showed that most of the physicians are measuring the patient’s weight each visit, which could be referred to that triaging process adopted in the medical wards and outpatient clinics include documenting the patient’s anthropometric measurements that include BMI. However, waist circumference measurement was less prevalent as it could be needed for specific cases and physicians might get sufficient data through BMI measurements.

Our findings revealed that more than half of the enrolled physicians initiated conversations with their patients about bariatric surgery, which could be referred to that bariatric surgery is one of the options in the treatment plan of those patients. This is evidenced by Allahverdi et al. who reported that bariatric surgery is becoming a major part of the treatment of morbid obese patients [20].

Moreover, the findings of the study showed that about two-thirds of the enrolled physicians had an access to appropriate resources and equipment for managing morbidly obese patients and were aware of whom they should contact when encountering any difficulty managing patients with morbid obese patients. This might be referred to that in the last decade, there was a significant increase in the bariatric surgeries performed in Saudi Arabia, which imposed the healthcare facilities, either public or private, to improve the resources supplies and experts in this field within the different healthcare settings. This is evidenced by Al-Khaldiet al. who reported increased prevalence of bariatric surgeries, even within private clinics and hospitals. Al-Khaldi et al. stressed the need for governmental monitoring over the bariatric surgeries due to the increased prevalence of those types of surgeries [21].

Further, the findings of this study showed that despite that the great majority of the enrolled physicians had referred patients to bariatric surgery, still a number of physicians reported different reasons for not referring, including lack of resources, lack of awareness about procedure and benefits, and concerns of follow up. This result might be attributed to that there are still specific concerns regarding the risks of complications of bariatric surgeries, the issue that could be considered a barrier for not referring patients to bariatric surgery. This result is evidenced by the findings reported by Altaf et al. study, which revealed a significant lack of awareness about the bariatric surgery benefits and risks, in addition to the absence of rules and regulations governing the bariatric surgeries in private healthcare settings, which caused a state of inconsistency about the knowledge and awareness regarding the bariatric surgeries [22].

Our findings revealed that Laparoscopic sleeve gastrectomy was the most ideal bariatric surgery as perceived by the enrolled physicians. This result might be referred to that this type of bariatric surgery is the most safe and effective bariatric procedure for obese and morbid obese patients. This result is supported by the findings reported by Gluck et al. and Elhag & El Ansari et al. who found that Laparoscopic sleeve gastrectomy is the most effective and safe bariatric procedure yielding excellent outcomes and least risks for obese and morbid obese patients, in addition to its capacity to address the metabolic derangements related to obesity. Moreover, it was found that this type of surgery is the most common and preferred type by patients, which could be referred to its effectiveness and its relative technical ease [23,24].

Moreover, it was found that less than 20% of morbidly obese patients inquire about the bariatric surgeries. This findings could be attributed to a significant lack of knowledge and awareness among morbid obese patients about the bariatric surgeries and its role in weight loss, which is evidenced by the findings reported by Bu Bshait et al. [25] who found that there is a lack of knowledge about the effectiveness, safety and complications of bariatric surgeries among Saudi adult citizens. In addition, Bu Bshait et al. [25] highlighted the lack of knowledge sources that could provide the patients with sufficient knowledge about the bariatric surgeries, as social media and word-of-mouth from patients who underwent bariatric surgeries were the most common sources of knowledge about bariatric surgeries [25].

Increased BMI and obesity comorbidities were reported significantly by the participating physicians as the factors influencing the decision to refer patients to a bariatric surgery. This result could be attributed to that resorting to bariatric surgeries occurs in case the aim of the treatment plan for morbid obese patients is to lose weight and reduce the morbidities of morbid obesity. These findings are in line with the results of Roberson et al. who found that reducing obesity complications and increased BMI that limits the patient’s physical activity were the main factors influencing the patient’s decision to undergo a bariatric surgery [26].

Exploring the physicians’ opinion about the bariatric surgery revealed that there is a high agreement that morbidly obese patients should try to diet for at least 6 months before considering surgery. This might be referred to the physicians’ belief that the surgical procedure should be the last option to lose weight among morbid obese patients, and this was evidenced by that the majority of physicians reported that they had morbidly obese patients who were successful at losing weight without surgery. Moreover, this result could be referred to that physicians seek to avoid any complications of bariatric surgeries especially that they reported that bariatric surgeries result in a sustained weight loss. However, the majority of the enrolled physicians reported that they are comfortable when explaining the procedure to a patient, which might be referred to physician’s sense of responsibility of educating patients and provide them with reliable information about the bariatric surgeries as an option of treating morbid obesity and reducing its complications. This is evidenced by that a great majority of the enrolled physicians were comfortable providing care to patients who underwent bariatric surgeries. Further, a significant number of physicians reported the need for further resources to get better knowledge about bariatric surgical care. This might be referred to the continuous developments of bariatric surgical techniques that require physicians to keep informed and updated in order to provide the highest quality of care.

Our findings suggested that medium aged physicians (36 to 45 years) and physicians who had 11 to 20 years of experience were more likely to refer patients to bariatric surgeries compared to other age categories. Yet, there is no established research-based evidence of the association of age with referral to bariatric surgery. However, this could be referred to that this category of physicians could be the most contemporary group of the beginnings of bariatric surgery and its developments within the last decades.

Finally, more than half of the surveyed physicians reported that 40 kg/m2 is the minimum BMI that would be considered to refer a patient without weight related comorbidities to a bariatric surgery. This might be attributed to that bariatric surgery should be performed to avoid any weight-related complications as a proactive procedure to avoid any future complications among obese and morbid obese patients. This is evidenced by the results reported by Haghighat et al. [27] who reported that bariatric surgery significantly reduces the long-term complications of obesity. In addition, the results of this study found that nearly half of the enrolled physicians are supportive for bariatric surgery for diabetic patients having BMI less than 35, whereas the other half were either non-supportive or unsure about this issue. This result highlights a consistency of knowledge about the need for bariatric surgery for diabetic patients and stresses the need for educational and research-based evidences related to conducting bariatric surgery for diabetic patients as a proactive procedure. Moreover, it was found that the majority of the physicians would refer a family member or a friend for gastric bypass surgery, which could be reflected to the physicians’ perceptions of the benefits of this procedure in controlling patient’s weight and reducing further medical complications.

Despite the promising findings of the present study, still there are a number of limitations that could limit the generalization of those findings. First, is the design of the study, which could impose a kind of bias in the responses, as the data collection tool was a self-filled questionnaire. Therefore, improving the design of this study and using qualitative data collection tool could yield more generalizable results. A second limitation is the geographical limitations, as the present study was conducted in King Saud University Medical City (KSUMC) and included family medicine, internal medicine and obstetrics and gynaecology physicians. Extending this study to include different healthcare facilities would improve the outcome of this study and provide better insight about the perceptions of Saudi physicians about the bariatric surgeries and its associated benefits and risks.

Conclusion

The world is facing a healthcare crisis with obesity and it is become apparent that obesity may in fact actually decrease life expectancy in the present generation. In addition, the cost of obesity is huge and gets a high share of the healthcare system expenditures in most of the countries around the world. This study provided an insight about the knowledge and perceptions of family medicine, internal medicine and obstetrics and gynecology physicians in KSUMC about bariatric surgery. The findings showed that there is a satisfactory level of knowledge and positive perceptions of physicians about bariatric surgery. However, lack of resources and lack of awareness were major reasons for not referring patients to bariatric surgery when needed. In addition, still there is a lack of knowledge regarding the ideal bariatric surgical procedure in the average patient, which highlights the need to educate the physicians about the differences, benefits and risks of different types of bariatric surgeries.

Based on the findings of the present study, the study recommends conducting educational sessions and training programs for family medicine, internal medicine and obstetrics and gynaecology physicians at KSUMC regarding the latest developments in bariatric surgery, in addition, to educating patients as well about medical conditions that require resorting to bariatric surgery.

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