THESlS

willIlllllllllfllllllll

017

This is to certify that the

thesis entitled

A Study of Attitudes and Beliefs about Obesity on
Second and Third Year Osteopathic Medical Students

presented by

Candace Bradley

has been accepted towards fulfillment
of the requirements for '

M.A. degmmin Interdisciplinary Programs:
in Health and Humanities ;

Wéruflmw m

Major professor

Date 14 l 98

0-7539 MS U is an Affirmative Action/Equal Opportunity Institution

 

LIBRARY

Mlchlgan State
University

 

 

 

 

PLACE IN RETURN BOX to remove this checkout from your record.
To AVOID FINES return on or before date due.
MAY BE RECALLED with earlier due date if requested.

 

DATE DUE

DATE DUE

DATE DUE

 

it o h 2002

 

 

AUG 2 9. 7838

 

 

731 r‘ 0?:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1/” WM“

STUDY OF ATTITUDES AND BELIEFS ABOUT OBESITY ON SECOND AND
THIRD YEAR OSTEOPATHIC MEDICAL STUDENTS

By

Candace A. Bradley

A THESIS

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

MASTERS OF ARTS

Department of Health and Humanities

1998

ABSTRACT

STUDY OF ATTITUDES AND BELIEFS ABOUT ON OBESITY ON SECOND AND
THIRD YEAR OSTEOPATHIC MEDICAL STUDENTS

By

Candace Bradley

Obesity in America s becoming a major community health issue. Obesity is a
contributing factor for diseases that require lifelong treatment such as diabetes high
cholesterol and coronary heart disease. Osteopathic physicians have been involved in
patient care and treatment for this disorder. The attitudes and beliefs about obesity can
be affected by the practice a physician words in and the teaching and training obtained in
medical school. This study examined six areas of interest that have an impact on the
treatment of patients who are obese as well as taking into account the training level, sex
and weight of the osteopathic medical students. These results were measured using a
questionnaire with sixty-five items asking various questions about obesity. This study
concluded that Osteopathic medical students do have adequate knowledge about obesity
which is based heavily on their past experiences. However, there is evidence proving that
these students also believe in some of the stereotypical myths about obesity. One of the
recommendations from this study is for the institution to provide more education on

causes, management, and counseling of obese patients.

Copyright by
Candace A. Bradley
1998

This is dedicated to my father, Dr. Jim Bradley, my mother Lela, and my husband Steve.
Dad, you are loved so much, and dearly missed.

iv

ACKNOWLEDGMENTS

This thesis has been a labor of love for me. Through the process of finishing it I
have had many life changing events occur in my life. Overall, I am proud of the finished
project and I hope that it will be of use for another study in the future. I would first like to
thank Dr. Howard Tietlebaum, my thesis director for his enthusiasm, patience, support,
teaching and guidance on this project. Because of you this became a positive learning
experience for me. I appreciated the time that you spent with me in getting this project
off the ground and running. I would also like to thank Dr. Harry Perlstadt for his
expertise, advice and support for my survey project. Dr. Joseph Papsidero, thank you for
sticking with me and for all of you encouragement during this process. I would also like
to thank Dr. Tom Tomlison for his guidance through the [PHI-I program.

I would also like to acknowledge my parents Dr. Jim and Lela Bradley. They
have constantly believed in me even when I didn’t, they pushed me and told me to start
“cutting the mustard”. With that in mind things came together. Since that time I lost my
father, but I know that he would want me finish what I have started. This is the strength
that I have learned from both of my parents and for that I love you both.

I would also like to thank my brothers James and Jason and my sister Wyetta for
being there for me. And I would like to thank a few friends who helped me with all of
the grunt work and gave me support. Lee, Dana, and Holly thank you!

Lastly, I would like to thank my husband Steve. You have put up with my

scattered paper mess for months, picked up the slack for me (which meant more work for

rlli.

 

you), dealt with my insecurities, and all the while supporting me and helping me get this

done. You are my soulmate, and my friend, thank you my love.

vi

TABLE OF CONTENTS

page

CHAPTERS

I. INTRODUCTION... .. 1
The Purpose of the Research
Research Questions
Limitations of Research
Statement of Design

11. REVIEWOFLITERATURE... 6
Attitudes and Knowledge About Obesity
Attitudes of Health Care Professionals
Doctor Patient Relationship
Obesity in America
Ethnicity
Risk Factors
Treatments
Osteopathic Medicine

Population and Selection of Sample
Instrumentation

Procedures

Data Collecting

Feedback

IV. ANALYSIS OF DATA COLLECTED... ...28
Demographics
Frequencies of Information
Analysis of Research Questions

V. SUMMARY, CONCLUSION, AND RECOMMENDATIONS ...... 53
Summary
Conclusion
Recommendations

vii

Cover Sheet
Obesity Questionnaire

VILLIST OF REFERENCES......

viii

63

68

LIST OF TABLES
page

TABLE 1 - Osteopathic Medical Students Future Practice Choice... .29
TABLE 2 - All Respondents Attitudes and Beliefs About Obesity... ..31
TABLE 3 - All Respondents Perception of the Etiology of Obesity... ...33
TABLE 4 - All Respondents Sources of Information About Obesity... ..34
TABLE 5 - All Respondents Recommendations for the Treatment of Obesity .35
TABLE 6 -AllRespondents Knowledge About Obesity... ...36
TABLE 7- Sex andRisk Factors...... 3....7
TABLE 8 - Men and Women’s Sources of Information About Obesity ........... 38
TABLE 9 - Men’s and Women’s Recommendations for the Treatment of
TABLE 10 - Men’s and Women’s Knowledge About Obesity... ...40
TABLE 11 - All Respondents Perception of Their Weight Compared to

TheirBMI...... ...41
TABLE 12 - Men’s Perception of Their Weight Compared to

TheirBMI... 4.1
TABLE 13 - Women’s Perception of Their Weight Compared to

TheirBMI... ....41
TABLE 14 - Weight andRisk Factors... ...42

TABLE 15 -Weightand Etiology ofObesity............ .......44

ix

TABLE 16 - Weight and Sources ofInformation About Obesity... ...45

TABLE 17 - Weight and Recommendations for the Treatment of Obesity ........ 46

TABLE 18-Weight and Knowledge About Obesity............... ......47
TABLE 19-Class and Attitudes and Beliefs About Obesity... .........49
TABLE 20-Class and Risk Factors...... 50
TABLE 21 -Class andEtiology ofObesity..................... 50
TABLE 22 -Class and Sources ofInformation About Obesity... ......51
TABLE 23 -Class andKnowledge AboutObesity......... ......52

CHAPTER I

Introduction

Obesity in America is becoming a major community health issue. Studies on the
increasing trend of weight gain by Americans have indicated that by the year 2030 the
whole population will be obese regardless of genetic make-up (Barr, 1996).

Obesity is a contributing factor for diseases that require lifelong treatment such as
diabetes, high cholesterol and coronary heart disease. An increase in these condition
among the patient population will increase the contact with physicians in the
management of a combination of health disorders. Thus, the problem of obesity and its
effects should be a primary concern for physicians and allied health services. The
osteopathic primary care physician has been involved in the traditional treatments of
obesity that have been centered around decreased calorie consumption and aerobic
exercise (Price, 1987). However, most treatments to date for obesity are not successful in
combating the long term goal of keeping the weight off permanently. This failure in
treatment could be seen as the fault of the patient but it might also be looked at as a
failure in communication between the doctor and the patient. Communication between
the osteopathic primary care physician and the patient is essential in the prevention and
treatment of obesity. Successful communication can only occur if the physician is
properly educated and sensitized to the issues of obesity. Attitudes and beliefs of
osteopathic physicians about the patients they treat can be an important factor in

successful prevention and treatment outcomes for obesity.

Purpose of the Research

Osteopathic primary physicians are in an optimal position to detect and treat
health problems like obesity in an ambulatory setting. Osteopathic physicians are
responsible for implementing maintenance and treatment plans for obese and overweight
patients. The attitudes and beliefs about obesity can be affected by the practice a
physician works in and the teaching and training obtained in medical school. At the
medical institution obesity education is sparse, which leaves the medical students with
very little experience and knowledge on how to interact with the obese patient.

Knowledge and understanding about obesity can improve the relationship
between the patient and physician, which in turn, can improve the treatment outcome.
This has been shown in doctor patient relationship studies where physicians that had
similar experiences with their patients where more successful in treatment. Therefore,
there is a need to assess what the attitudes and beliefs are of osteopathic medical students
before they begin to practice. Attitudes and beliefs that are acquired from either their
own personal experiences or what they have learned in medical school, may carry into
the clinical aspect of training and affect how these patients are treated.

A review of literature from articles on attitudes and beliefs have been done on
only allopathic physicians and medical students by Blumberg in 1980. To date, a study
on osteopathic students has not been attempted concerning this issue. This study will
examine the attitudes and beliefs of second year and third year osteopathic medical

students on obesity at Michigan State University. At the College of Osteopathic

Medicine, second year students are involved in the two year academic portion (e.g. non-
clinical) of the curriculum. This includes all of the basic biological sciences courses
(biochemistry, microbiology, etc.), biological systems courses (cardiology, respiratory,
etc), as well as training in techniques of manipulative medicine and basic clinical skills.
At this point in time, second year osteopathic medical students have had very little
clinical experience with patients. The third year osteopathic students have started the
two year clinical portion of the curriculum called the extemship which is completed at an
affiliated Osteopathic hospital of the students choice in Michigan. This experience
includes clinical rotations at the osteopathic base hospital and training in an ambulatory
care or practice setting.

The investigative areas of interest that will be examined are: (1) do osteopathic
medical students believe that obesity is a serious health risk; (2) what are the students’
beliefs regarding obesity; (3) do students have stereotypical attitudes towards obese
patients; (4) how much knowledge do the students have on obesity; (5) where have the
students received most of their information on weight control; and (6) what resources do
the medical students think they will use when treating obese patients. The people who
may find this study beneficial could be academic personnel in charge of setting the
curriculum, teaching faculty at the medical school and hospitals, the osteopathic medical
students, and Osteopathic physicians in general. The findings of this study could be
added to the limited inquires into this area by obesity researchers and be useful in
comparative analysis of data from several sources.

To measure the attitudes and beliefs of osteopathic students a survey was created

using a combination of James Price’s questionnaire from his 1987 and 1989 studies on

attitudes and beliefs of physicians, and Mary Harris’s true/false knowledge questions
from her 1983 study that included knowledge and attitudes towards obesity. The survey
was modified to the level of a medical students knowledge base. Once the survey
instrument was submitted and approved by the University Committee on Research
Involving Human Subjects (U CRIHS) at Michigan State University’s campus it was

administered to second and third year osteopathic students.

Research Questions

In order to study the problem the following research questions were proposed.

1. Is there a difference between men and women osteopathic medical students in
knowledge, attitudes and beliefs about obesity in the areas of prescribing weight loss
programs, health risks, etiologies, information, and treatment recommendations?

2. Is there a difference between overweight and non-overweight osteopathic medical
students in knowledge, attitudes and beliefs about obesity in the areas of prescribing
weight loss programs, health risks, etiologies, information, and treatment
recommendations?

3. Is there a difference between second year and third year osteopathic medical students
in knowledge, attitudes and beliefs about obesity in the areas of prescribing weight

loss programs, health risks, etiologies, information, and treatment recommendations?

4. What are the Body image perceptions of the second year and third year osteopathic

students based on their Body Mass Index (BMI) and their own interpretation?

Limitations of research

The boundaries of this research are as follows: (1) This survey was only
administered to second and third year students at the College of Osteopathic Medicine at
Michigan State University in East Lansing, MI; (2) A population size of two hundred and
fifty students in the class of 1998 and 1998 at the College of Osteopathic Medicine were
used for this study; (3) The survey template from Price’s study will be modified to
reflect the experiences of medical students, who have had limited clinical experience;

(4) The study adheres to the guidelines that have been set for the use of human subjects

by the University Committee on Research Involving Human Subjects (UCRIHS).

Statement of Design

This study will follow the quasi-experimental design methodology. A
comparative analysis of males and females, overweight and non-overweight , and those
students without clinical experience (second year osteopathic medical students) and those
with clinical experience (third year osteopathic medical students) is investigated. The
use of frequencies and crosstabulations is the main form of statistical analysis. A survey
of sixty—five questions was administered to the selected population of osteopathic

medical students with fifteen minutes allotted for the completion of the survey.

CHAPTER II

Review of Literature

The review of literature for this research has been divided into three major
categories: the first encompasses literature dealing with attitudes and knowledge about
obesity, in general and from health professionals; the second category deals with general
literature concerning obesity; and the third category deals with the field of Osteopathic
Medicine.

Attitudes and Knowledge About Obesity

For purposes of this review, articles relating to attitudes and knowledge will deal
with the topics of body image, and the attitudes of health care professionals.
Body Image

Body image is defined as how a person feels about their body. This term is not
only concerned with the external appearance of a person but also the beliefs, feelings,
sensations, and perceptions about the persons body. Garner (1996) has found that most
of the information on body image is based mostly on research from studies on women.
Research on men has been extremely limited in this field. Another limitation on the
information about body image is that most of the subjects are from clinical populations.
These individuals usually have serious psychological disorders such as anorexia nervosa
and bulimia. Culture plays a major role in the perception of body image. Attitudes of a
culture about obesity can have a serious impact on an individuals perception of
themselves. In the United States the westernized concept of thinness contributes to a

negative body image. Gamer’s study concluded that women who have a negative body

image should try to find self-acceptance and not rely on cultural messages of achieving
unrealistic thinness to feel good about themselves.

Wright and Whitehead (1987) reviewed the literature on body image and related
obesity perceptions over a twenty year span Wright and Whithead found that obesity is
defined by cultural perceptions of beauty. This allowed them to understand the
sociocultural dimensions of body size perceptions. Societal perceptions about obesity
have an impact on individuals whether they are obese or not Here in the United States
negative attitudes towards fatness and the stigmatization of being overweight is
experienced. However, in other cultures on the world like Nigeria, overweight is seen as
a symbol of wealth and good health. Wright and Whitehead found fi'om their literature
review that individuals in the US regardless of weight had an incorrect perception of their
body image. Subjects that were of normal weight thought they were too heavy than they
really were. Wright and Whitehead both agree that more research should be done in this
area.

Cocker and Comwell (1993) found in their study that obese persons have a lower
self esteem when compared to non-obese persons. The lower self esteem is connected to
the subjects perception of their own body image. Cocker and Comwell’s study used
college women of various weights that were then interviewed by a male evaluator. The
male evaluator was instructed to give a variety of reactions ranging from positive to
negative feedback regardless of the physical appearance of the subject. Relative to other
groups, overweight women who received negative feedback attributed the feedback to
their weight and did not blame the evaluator for his reactions. The stigma of being

overweight made these women internalize these reactions even though it was not a

reaction personally aimed at them. Low self esteem and a distorted body perception can
make these individuals believe that the negative outcomes in their lives is due to
prejudice about their weight.

Robinson and Bacon (1993) examined the issue of fat phobia in their study.
They defined it as a pathological fear of fatness. They developed and conducted a Fat
Phobia Scale questionnaire (FPS) to determine how treatment can help reduce this
disorder. The survey was given to patients before and after treatment, to see if there
would be any difference. It was found that after treatment which consisted of
psychological therapy and education on health and nutrition, the score on the FPS
questionnaire had decreased. They believe this decrease was attributed to education
about body image and nutrition.

In Naomi Wolf’s 1991 book the Beam Myth, she argues that the negative
body image that women have about themselves is a form of control to keep women from
being truly liberated. She states that even though women have more money and power
today than in the past, women feel worse about themselves psychically. “During the past
decade, women breached the power structure; meanwhile, eating disorders rose
exponentially and cosmetic surgery became the fastest-growing medical specialty.” She
states that this standard of “beauty” is not about women, but about men’s institutions and
institutional power to take away that the feminist movement brought to women and could
have brought to future generations of women.

Harris and Waschull’s (1990) study using 47 women and 8 men responded to a
questionnaire that dealt with various aspects of motivation to lose weight, knowledge

about obesity, and personal and societal attitudes toward the obese. Their study found

that: (1) subjects had reduced caloric intake and increased exercise when trying to lose
weight; (2) verbal motivation was only partially effective even after the individual had
spent large sums of money on weight loss programs; (3) knowledge about obesity was
lower than expected from the 47 women in the study. However, thinner subjects had
more knowledge than heavier subjects; (4) more women expressed a desire for thinness
than men; and (5) all subjects reported an awareness or experience of negative social
stereotypes directed at obese people and blamed themselves for being overweight. Harris
and Waschull both agree that there is a challenge facing the health care profession to
encourage women to shifi their concern from their physical appearance but to set a goal
of long-term health. Harris and Waschull study is useful when looking at women’s
attitudes and knowledge based on the size of the sample population, however, the
number of men is not a good representation to base how a whole population of men may
feel in this study.

Ben-Tovim (1994) conducted a similar study in Australia and found that body
attitudes are independent of current physical condition of the women. These attitudes
were measured using the Ben-Tovim-Walker Body Attitudes Questionnaire (BAQ).
Attitudes were found not to vary substantially with age, and that the Body Disparagement
and Feeling Fat and Lower Body F atness sub scales of the BAQ were correlated with
BMI. Obese subjects in the study felt significantly less attractive than those with a BMI
slightly over the national average.

Roth and Armstrong (1993) developed a questionnaire that assesses the
variability of bodily feelings of thinness and fatness across life situations. The Feelings

of Fatness Questionnaire (F OF Q) and other surveys like the Eating Attitudes Test, the

10

Beck Depression Inventory, and three other conventional measures of perceptual and
cognitive-affective body experiences test were used. This questionnaire was
administered to 132 undergraduate women with a mean age of 18.6. Roth and Armstrong
concluded that the FOFQ demonstrated a wide variety in responses and that it could be a
result of psychosocial perceptions that caused the undergraduate women to feel fatter

than they really were.

Attitudes of Health Care Professionals

Attitudes of health care professionals have a great effect on patient outcomes
when dealing with the obese patient. Friedman et al (1995), did studies comparing obese
and non obese persons in which they found that being obese does not carry the risk factor
for psychological problems. This finding is a contraindication to what the clinical
impression is about obesity.

Wiese (1992) did a study to evaluate an educational intervention design to modify
the stigma held by first year medical students. In this pilot program a selected group of
medical students took a course that dealt with the issue of obesity. Prior to the course
these medical students held accurate beliefs about the causes of obesity but they still
maintained negative stereotypes of obese persons being lazy and lacking self control.

The course included obesity subject matter utilizing audio, video, and written
components. Analysis of this group of students over a year after the course indicated that
the course was effective in changing the attitudes about obesity from blaming the patients

for their condition to understanding the role of genetics and environmental factors.

ll

Cade and O’Connell (1991) used a questionnaire to assess general practitioner’s
knowledge, attitudes and current practice of treatment regarding obesity and weight
problems in England. The majority of the doctors surveyed had tried to lose weight at
least once in their lives. The doctors reported that the most popular means of treatment
of obesity was through one on one patient counseling. This included information on diet
and suggestions of exercising. Most doctors in this study felt that they were less effective
in accurately helping the patient lose weight. Clinical experience with obese patients
was noted as the most important factor in patient management and medical school was
noted as the least important. Cade and 0’ Council both agree that medical schools and
postgraduate centers should play a more important role in educating doctors about
nutrition and obesity.

Price et a1 (1989), conducted a study using 500 pediatricians examining their
perceptions and practices concerning childhood obesity. When examining attitudes and
beliefs on obesity a majority of pediatricians believed that normal weight is very
important to the health of children. The pediatricians also felt that childhood obesity is
the cause of peer rejection, and a variety of risk factors that include coronary artery
disease and diabetes. The majority of doctors received their knowledge on obesity
through medical journals and past clinical and personal experience.

Price et al, (1987) did another study on the beliefs and attitudes of family
practice physicians regarding obesity. He found that attitudes beliefs and practice
differed significantly based on the physicians sex, weight, experience, and how they felt
about counseling obese patients. Price found a population of physicians that held

negative or stereotypical attitudes toward obese patients. The majority of physicians

12

agreed that a decrease in caloric intake was a good method of weight loss. Price
concludes that based on this study there is a need for education when it comes to dealing

with obese patients.

Doctor Patient Relationship

The doctor patient relationship is very important in the overall treatment of
obesity. Family physicians are faced with problems for caring for obese patients. Adams
and Smith (1993) studied how the doctor patient relationship can affect the risk of
endometrial and ovarian carcinoma. Adams and Smith found through their study that
there was a difference in the frequency of pelvic exams on non-obese and obese patients.
This study also examined the effects of physicians and patients attitudes towards obesity
on the examination frequency. Data reported in their article suggest that attitudes and
behaviors are negatively influenced by the patients weight. As the patients weight
increased their reluctance to be examined also increased. A majority of physicians
indicated that they were reluctant to perform pelvic exams on obese patients.

Murphee’s 1994 study on patients attitudes towards doctors put together a focus
group of obese patients to discuss weight loss therapy from a patients’ point of view.
Three sessions were completed which included topics such as the patients feelings and
life experiences, exercise and eating habits. The role of the traditional medical approach
to weight loss therapy was also discussed. Murphee’s results concluded that all
participants reported to having negative life experiences, job discrimination, and

derogatory remarks that they attributed to their weight.

13

Adams and Smith found similar findings to Murphee’s study. As subjects weight
increased negative opinions about the subjects appearance and reluctance to obtain pelvic
examination also increased. This resulted in the likelihood of these subjects not having
an annual pelvic examination.

Murphee concludes that the support group felt that the traditional form of
treatment of obesity was not helpful and that a group approach would be better. Adams
and Smith concluded that if physicians are reluctant to perform pelvic exams and obese
women are also reluctant to have them done then this lack of screening can increase the
risk of cancer for these patients.

Sttmkard (1996) believes that discrimination against obese persons is said to be
the last form of accepted prejudice. This prejudice occurs among physicians and health
workers. The attitudes of physicians are developed early in their medical training.
Stunkard believes that physicians hold negative, moralistic attitudes towards obese
persons and that these attitudes persist throughout their careers. He contends that this
type of discrimination is even found in physicians who specialize in the treatment of
obesity. The myths about obese persons having lack of will power, and that they are self

indulgent or lazy, helps to perpetuate these negative attitudes about obese patients.

Obesity in America

Trends of Obesity in America

Obesity in America has become a major health concern for the current and future

populations. Numerous studies have shown that obesity is increasing overall in all

14

western cultures. Data from Kuczmarski ‘sl992 study using the second National Health
and Nutrition Examination Survey (NHANESH) indicated that in the period of 1976-
1980 approximately 34 million US adults (25.7%) were overweight. The study also
indicated that more women (19 million) were overweight than men (15 million). Select
demographic factors such as low educational attainment, low socioeconomic level, were
associated with the prevalence of overweight with the incidence of weight gain. This
alarming increasing has experts on obesity claming that by the year 2030 the entire US
population will be obese regardless of genetic make-up (Barr 1992). Since the mid 80’s
there has been a resurgence of health and fitness that has become a billion dollar
industry. In the 1970’s the diet industry revenues averaged 10 billion dollars. Today the
diet industry revenues exceeded over 33 billion dollars. Approximately 80% of women
are dieting as compared to 25% of men who diet in America. Americans spend more
money on excretes equipment, fat-free foods, gyms membership, work-out videos, and
weight loss programs than any other nation. Levy (1993) found through a phone survey
on ways to lose weight, how diverse individual practices are. Despite all of these effort
Americans are still gaining weight.

In the field of weight control there are two terms that are commonly used. From a
researches perspective interpretation of obesity is complicated by the realization that
there is no absolute definition nor universal measurement standard for assessing fatness.
In an effort to clarify this problem Wright (1987) suggests this own interpretation of a
definition for obesity and overweight. Obesity refers to adiposity and a surplus of body
fat Overweight denotes an excess in body weight relative to a selected standard.

Sichieri and Everhart (1992) described underweight and overweight based on five recent

15

relative weight classifications. These classifications are based on Body Mass'Index in
the adult population in US. The BMI is used by health care professionals to determine if
a person is at a health risk from excess weight.

BMI as described by Murphee (1996) and Williamson (1993) is the weight in
kilograms divided by the height in meters squared. A BMI between 25 and 30 means that
a person is overweight. A BMI of 30 or more means that a person is obese. This finding
conflicts with Williamsons Study. A BMI of 27.8 or more in men and 27.3 in women
classifies them as overweight. This value is 20% above the desirable weight according to
the 1983 Metropolitan Life Insurance Compmy tables.

So why are Americans getting heavier? Dwyer (1996) attributes America’s
obesity to changes in two areas; food and lack of physical activity. There are two main
technological and social advances that were not around 35 years ago. The microwave
oven has revolutionized the way Americans eat. More foods are preprepared for quick
eating.

The number of obese and overweight people is increasing inspite of the current
trends towards healthier eating habits. Dwyer states that the second advance contributes
the reason why Americans are getting heavier. Dwyer believes that all of our
advancements have created more leisure time. Most activities that Americans do involve
inactivity like watching the television or using a computer. Americans are no longer
forced to be physically active. As our culture advances technology we tend to be less
active. Most Americans are no longer physically active because there is no longer a need
to be. Automobiles and public transportation have stopped Americans from being

physically active in their daily lives unlike fifty years ago.

16

So who’s trying to loss weight in America? According to Horm and Anderson
(1993) approximately 44 million people over the age of 25 were trying to loss weight in
1990. Approximately 60% of men and 59% of women were trying to lose weight by
increasing their physical activity. Over one third of Americans in this study saw
themselves as overweight. However, only two thirds were actively trying to lose it. The
majority of Americans in the study are using a combination of eating less and an increase
of physical activity.

In Russell and Williamson’s 1995 study their analysis was to estimate the
magnitude of weight change within a six year period between 1994 and the Year 2000.
Their study questioned if Americans could reach the Healthy People 2000 goal for the
reduction of overweight people among those ages 20-74, to no more than 20% among all
adults and no more than 30% among black women. Prevention of weight gain among
non overweight is compared with that of weight loss among the overweight as strategies
for reaching this goal. Their study went as follows: 1) Data from the NHANESI and the
Nutritional Examination Survey Epidemiological Follow-up Study (NHEFS) were used to
estimate the 6 year weight change of persons aged 20-74 at the year 2000. Men and
White and Black women, were examined in addition to the overall population. Russell
and Williamson (1995) found that prevention only was successfirl in reducing the overall
prevalence of overweight individuals by 20% and it was only successful in those who
were not already overweight. Russell and Williamson concluded that even in the six year

period the goal of weight reduction by the Year 2000 could not be reached.

17

Ethnicity

Ethnicity plays an important determinant of obesity (Pawson, 1991). Minority
populations have a higher prevalence of obesity and thus experience its adverse health
consequences disproportionately. Many studies have been done that examine the risks of
minority populations in comparison to Caucasians. Steven’s (1994) found that the
prevalence of obesity in African-Americans is approximately twice that of White women.

Minority populations are important when looking at weight changes because
currently there is a shift in the demographic numbers of all minorities that will be
apparent by the year 2020. In 1984 African-Americans and Hispanics are about 35
percent of the total US population. Within the next century the non-Hispanic white
majority in the US will become the minority. The Hispanic population in the United
States is becoming the fastest growing population and will increase to become the largest
“minority” group. The United States of the future will be very different from the United
States of today. The population will be older, more diverse ethnically and approaching
the 400 million mark by the year 2050.

Malina (1993) like Williamson found that the prevalence of obesity is increasing
in the US children and youth ages 6-17. Using the triceps skin fold test and Blvfl, Malina
found that prevalence of obesity is also attributed to ethnicity. The prevalence of obesity
has also increased in Mexican American and American Indian children. Sichieri (1992)
also found that Black and Mexican women have the highest incidence of being
overweight. Jeffery (1991) stated that population differences in obesity could be due to
three things; 1) biologic susceptibility; 2) treatment availability or effectiveness; and 3)

shared behavior patterns leading to caloric imbalance. Jeffery states that the only way

18

that the trend of obesity can be stopped is by introducing prevention programs that
address the inequalities of education, treatment services and environmental opportunities.
Along with these considerations and other ways to counteract the increasing trend in the
United States towards over nutrition in the population as a whole.

Recent studies have been done that link obesity and socioeconomic status
together. A study by the New England Journal of Medicine (1993) found a striking fact
about obesity and the inverse relationship between obesity and socioeconomic status in
the developed world. This correlation is very apparent among women. There are at least
three possibilities why this occurs; 1) obesity influences economic status; 2)
socioeconomic influences obesity; and 3) there is a common factor that influences both
obesity and socioeconomic states. Stern found that when looking at Mexican American
populations obesity increased as socioeconomic status increased. Stern felt that the role
of poverty as an independent influence on obesity level seems minor when compared
with other cultural deterrnents. In African American women there is a decrease in weight

with an increase in socioeconomic status which is similar to the trend in Caucasians.

Is obesity a Chronic or Social Disease?

Recently there has been debate on whether obesity is a chronic or social disease.
Traditionally it had been viewed as a social disease. The sociology behind obesity has
been directly linked to economic status, education, and race. Despite the correlation
between obesity and other health risk factors little recognition has been given to the fact
that obesity itself fits the criteria of chronic illness. Stunkard (1996) describes chronic

disease as a disorder that disrupts the function of the body that develops slowly and

l9

persists over an extended period, often for the life of the individual. Treatment for a
chronic diseases focuses on alleviating the symptoms rather than curing it. Bray and
Grey (1988) compared obese patients and patients with hypertension. Like a chronic
disease, obesity may require chronic treatment. Many obese patients like hypertensive
patients are unwilling to seek medical help, follow a prescribed regimen of continued
medical help, or continue to follow the treatment when related side effects are
experienced Yanovski (1993) argues that although obesity fits the model of a chronic
disease it is rarely considered to be a disease at all. Stunkard believes that obesity must
be recognized as a disease and not as a subacute illness that will respond to a time
limited course of treatment and eventually be cured. This approach in the treatment of
obesity has shown that even the most motivated patients treated with these current
techniques of massive weight loss regain most of the weight back and more within a five
year period Yanovski asserts that regarding obesity as a chronic disease of multifactoral
origin has several benefits; 1) it decreases the stigma associated with obesity; 2)
recognizes it a heterogeneous disorder and like hypertension should be treated on an
individual basis; and 3) encourage physicians and their patients to develop realistic
treatment goals.

DiPietro (1995) found among minorities, persons of lower socioeconomic status
and lower educational attainment are the two risk factors that are in common to become
obese. They are overweight and sedentary behavior. These two factors contribute to
chronic state of the illness. In order to reduce the morbidity and mortality associated
with being overweight, obesity and sedentary behavior, there needs to be an emphasis for

intervention programs directed at persons in these groups.

20

Risk Factors

Obesity and being overweight are the causes of a multitude of health problems. It
has been estimated that 280,000 deaths a year are attributed to ovemutrition making it
second to smoking as a cause of death Stunkard (1996) states that obese persons are at a
considerably higher risk for developing hypertension, insulin resistance, and coronary
heart disease. Pi-Sunyer (1993) assessed the health hazards of obesity and found that the
measurement of obesity must take into account the multiple factors including genetic,
cultural, socioeconomic, behavioral, and situational mechanisms. Pi-Sunyer indicated
that there are several problems that complicate the evaluation of the health hazards of
obesity . He believes that the definition of obesity is imprecise. The division of a
population into non obese and obese persons without an understanding of how heavy
does a person have to be before their weight puts them at risk for mortality and
morbidity. Second, a persons weight may be related to current health practices or health
status (i.e. smoking, or drinking) . Thirdly, follow-up care can determine the prognostic
importance of body weight and the relationship between obesity and disease outcomes
varies with the age of the study group.

In obese persons the distribution of the body fat can contribute to other health
risks. Stunkard states the upper body obesity predisposes the individual to coronary heart
disease regardless of their overall obesity. McGinnis et a1 (1993), Pi-Sunyer, and
Stunkard all agree that obesity is associated with noninsulin dependent diabetes mellitus
(NIDDM) or type II diabetes, colon cancer, and coronary heart disease. Pi-Sunyer cites

that obesity also causes gallbladder disease which occurs four more times in obese than

21

nonobese persons. The mechanism for gallbladder disease is due to cholesterol
supersaturaion which is one of the contributing factors to coronary artery disease that
causes atheroscerolsis as well. Obesity can also cause respiratory disease which includes
sleep apnea, irregular breathing and severe hypoxia. Cancer is also increasing in obese
persons. For overweight men there are high mortality ratios for colorectal and prostate
cancers. Overweight women have higher mortality ratios for cervical, ovarian, breast,
and endometrial cancers. Pi-Sunyer states that further studies need to be conducted to
determine if it is really obesity that is the cause in these cancers or if it is related to the
diet. The effect of obesity can also cause gout in men. As the BMI increases from 21 to
31 so does the uric acid level in the body which causes gout. There is also an increase in
frequency of osteoarthritis due to the increased weight.

Pi-Sunyer, Stunkard, Williamson, and McGinnis all agree that obesity increases
both morbidity and morality risks. The increase in mortality and morbidity is greater in
men than in women, and for those that are younger than 50 years old. This suggests that
weight gain should be prevented before this age. From a public health standpoint the US

should urge all persons to maintain an average weight to avoid these risks.

Treatment

Currently, the goals of treating obesity have changed in the medical field. In the
past treatments have emphasized the importance of achieving the ideal weight for that
person. Anything achieved less than the ideal weight was seen as a failure, and the
patients inability to control their dietary intake. Now there is evidence that show how

weight loss of 10% or less of total body weight is sufficient enough to greatly reduce the

22

medical complications of obesity. Obese patients are no longer stressed to reduce to an
ideal weight, but instead focus attention on losses of 5% to 10% of body weight and long
term maintenance of body weight. There are three methods of weight loss treatment
according to the Institutes of Medicine are as follows: 1) “Do it yourself” programs that
include diet books, Take Pounds Off Sensibly (TOPS), Overeaters Anonymous, and
cookbooks for healthier eating. 2) “Non clinical” or commercial programs such as
Weight Watchers, Jenny Craig and professional fitness trainers; and 3) “Clinical”
programs that provide medical care in conjunction with more aggressive therapies, such
as very low calorie diets, liquid diets, medication or surgery.

Behavior therapy is also used as a means of treatment in obesity. In consists of a
set of principles and techniques designed to modify eating habits and physical activity.
Usually behavior therapy is done in a group setting. So far the best long term result have
been obtained by Bjorvell and Rossner who treated severely obese patients in an
outpatient program and showed that long term maintenance is possible, but it was
achieved only wit a very heavy investment of time and money.

Phannacotherapy has become very popular in the treatment of obesity. Atkinson
and Hubbard (1994) concluded that pharmacological agents may be effective in reducing
body weight over an extended period of time. Their study showed that drugs should be
used only as one component to comprehensive weight reducing program. Atkinson and
Hubbard stressed new research is needed when examining the long term efficacy and
safety of drugs of obesity treatment.

Low caloric intake is another method of treatment. These very low diets consist

of 800 to 1200 kcal per day diets. They produce a weight loss of approximately 1.5

23

kg/wk in men and 2.0 kg/wk in women. These diets provide enough protein to eliminate
lean body mass loss and are safe when limited to 12 to 16 weeks under some type of
monitoring system.

Stunkard believes that very low calorie diets have several shortcomings and
require medical supervision. This can be expensive and inconvenient for patients. The
patients usually end up gaining back the weight and more. Gardner (1991) study found
that very low calorie diets sponsored by agencies like Jenny Craig have most of their
participants gain back the weight and more. Dyer (1994) states that the traditional
treatment of obesity includes a change in lifestyle, nutritional education and
modification, and increase in exercise. Dyer stresses that treatment should encompass

the need of the individual.

Osteopathic Medicine

The medical field has a major challenge to ensure that patients health can be
achieved by lowering the incidence of obesity and its associated risk factors. This study
will concentrate specifically in the area of Osteopathic medicine.

In America today there are currently over 33,000 Osteopaths practicing in the
areas of primary care which includes pediatrics, and internal medicine. A Doctor of
Osteopathy or a DD. is a complete physician who is licensed practice medicine. DOs are
required to complete four year of medical school like MDs however, the difference is the

holistic focus and use of manipulative medicine. The profession was founded by Dr.

24

Andrew Still who established the philosophies of what a DO should be and do. First he
believed that a DO physician should do no harm, and should treat the patient not the
disease. He also believed that a physician should look beyond the disease for the cause
of illness, this is centered in a more holistic approach. Dr. Still believed that physician
should understand the practice of medicine is based on sound scientific principles. And
that when the body is functioning optimally the body has the potential to make all
substances necessary for health and well being. And lastly he believed that the nervous
system influences all body functions.

It is projected that by the year 2000 there will be 45,000 osteopathic physicians
practicing in the United States. Currently DOs represent approximately 5.5% of the total
United States Physician population as well as 18% of military Physicians. It has been
estimated that DOs see about 100 million patients a year.

Michigan State University’s College of Osteopathic Medicine was established in
the early 1970’s and graduates over 100 osteopathic doctors per year. Currently, the
academic curriculum at the college consists of training in all of the basic sciences,
behavioral sciences, clinical skills, osteopathic manipulative manual, systems courses,
and a doctor patient relationship course. The clinical portion of the curriculum which
begins in the third year consists of a variety of clinical rotations to be completed at a base
hospital in the state of Michigan.

The future of osteopathic physicians will be treating a patient population that is
obese. The challenge for DOs will be if the princples and philosophies of the profession
can meet the needs and provide successful health care for the growing obese patient

population.

CHAPTER III

METHODOLOGY

The information given in Chapter III is presented under the following divisions: a)
Population and Selection of the Sample; b) Instrumentation; c) Procedures; d) Data
Collecting; and e) Feedback.

Authorization at Michigan State University for this study was approved by the

University Committee on Research Involving Human Subjects (UCRIHS).

Population and Selection of the Sample
The population under investigation in this study consists of approximately two
hundred and fifty students who will graduate from the College of Osteopathic Medicine
in May of 1998 and May of 1999. The age of the population ranges form 23 to 55. The
ethnic backgrounds represent a majority of Caucasians along with African Americans,

Asian Americans, Hispanics Native Americans, and Pacific Islanders.

Instrumentation
The instrument that was used in this research study was a modified version of an
attitudes and belief questionnaire developed by James Price. In his 1989 study on 500
pediatricians attitudes and beliefs about obesity the questions focused on the clinical

aspects of obesity and its treatment. Portions from James Price’s 1987 survey on 318

25

26

family practitioners was also used for sources of information and recommended
treatment options. These non reported, but often used questionnaires have been
modified to encompass the level of knowledge and experience that the medical students
have acquired at this stage. The instrument has seven areas of study: (1) Osteopathic
medical students beliefs on prescribing weight programs for patients; (2) Osteopathic
medical students beliefs regarding obesity: (3) Role of obesity in health risks; (4)
Osteopathic medical students perceptions of the etiology of obesity; (5) Sources of
information about obesity; (6) Weight loss programs; (7) and Personal demographic
information. Six questions from Mary Harris’s true/false obesity knowledge questions
from her 1983 study on 222 Australian university students are modified and utilized as
well. See Appendix A
Procedures

Distribution of the survey instrument will be to second and third year students.
Participation in this study was strictly voluntary, and subjects were asked to participate
via a cover letter attached to the survey. The surveys were distributed at a mandatory

meeting for both sets of selected populations.

Data Collecting
The data from the surveys was entered without reference to name or address of
respondent. Anonymity will be preserved. A total of 190 surveys were distributed to
both classes and 165 were collected. The data was reported in summery fashion only.

The SPSS Statistical program will be used to analyze the information.

27

Feedback
Arrangement of feedback of the data will be assessed and the discussion of the
finding will be presented in the Masters thesis defense. All information on al of the
participants was gathered in the strictest of confidence and this degree of confidentially is

assured.

CHAPTER IV

Analysis of Data Collected

The analysis of the data collected from the obesity questionnaire will be presented
in this chapter.
Demographics

A total of 165 osteopathic medical students returned questionnaires after being
administered. However, one of the returned questionnaires was not completed . This
brought the total number of questionnaires to be analyzed at 164 (65%) out to the
possible 250 respondents. Questions fifty-eight through sixty-five itemized the
demographics of the students in which year born, sex, weight, height, self perception of
weight, ethnic background, area of preferred future practice, and class were asked. From
the class of 1998 there were 51 respondents and from the class of 1999 there were 111
respondents. The proportional allocations of the two classes are as follows; The total
number of potential respondents for the class of 1998 is 119 students, there are 68 men
and 51 females. This is a 121.3 ratio. In the class of 1999 the total number of students is
133, there are 76 men and 57 women. This is a ratio of 121.3. A total of 84 men and 80
women responded with complete questionnaires that were used for analysis. From the
class of 1998, twenty eight women and 23 men responded and from the class of 1999,
fifty-four men and 57 women responded. The ratios of men to women in this study are

representative of the actual number of possible respondents, (the class of 1998 1:1, and

28

29

the class of 1999 1:1), therefore minimizing the non response bias. Ninety-eight of the
osteopathic medical students (59%) perceived their weight appropriate, 31% felt they
were too heavy and 7.2% felt they were too thin The ethnic background included 116
(69%) Caucasians, 18 (10%) Asian/ Pacific Islanders, 15 (9%) Afiican Americans, and 2
(1.2%) Native Americans. However, for the purpose of this study race was not used.
The average age of the respondents was 26. About one-third of the students (31.9%)
indicated that they intend to go into family practice, while 15.1% preferred internal
medicine, 15.7% other non-specific, and 7.2% preferred pediatrics for their future
practice. Other choices listed were obstetrician/gynecology (3.0%), Psychiatrist (3.6%),
medical subspecialty (2.4%), other medicine (6.6%), general surgery (3.6) surgery

specialty (3.6%), and surgery subspecialty (1.2%). Items are listed in Table l.

 

TABLE 1

Osteopathic Medical Students Future Practice Choice
Type of Practice “/-
Family Practice 31.9
Other- Non Specific 15.7
Internal Medicine 15.1
Pediatrics 7.2
Other Medicine 6.6
Surgery Specialty 3.6
General Surgery 3.6
Psychiatrist 3.6
Obstetrician / Gynecologist 3.0
Medical Subspecialty 2.4
Surgery Subspecialty 1.2
n=156

 

30

Overall Summary

To analyze this portion of the survey questions one through fourteen strongly
agreed and agree were combined. A majority of the osteopathic students believed that
“maintaining a normal weight is very important to the health of the patient” (98.7%), and
that it is the physicians obligation to counsel obese patients about the health risks of
obesity (97.6%). Seventy-one percent believed that designing programs and counseling
patients is difficult. However, 11.5% believed that counseling patients about weight loss
is inconvenient. The respondents agreed that counseling patients about weight is
professionally gratifying (65%), and that society is not doing enough to help alleviate
obesity (71.1%). All respondents believed that physicians should be role models by
setting an example as one who maintains a normal weight (87.2%), and only 47.5% felt
confident in prescribing weight loss programs. When asked if obesity is becoming more
prevalent 89.2% of the respondents felt that it was. All respondents also agreed that
obese patients appear to have more medical problems that non-obese patients (86.6%).
Just over half (5 1. 1%) of the students believed that alleviating childhood obesity is more
important that alleviating adulthood obesity. When asked if obesity is a significant cause
of peer rejection 89.2% agreed that it was, and that with proper guidance formerly obese
patients are able to maintain their weight (79.1%). The students believed (61.6%) that
with proper guidance formerly obese patients are able to maintain their weight. Beliefs
regarding prescribed weight programs and beliefs conceming obesity are identified in

Table 2.

31

 

TABLE 2
All Respondents Attitudes and Beliefs About Obesity
Agree and Strongly Agree
%
Maintaining normal weight is very important to the health of the 98.7
patient.
Physicians are obligated to counsel patients about the risks of 97.6
obesity.
Designing programs and counseling patients is difficult. 7].]
Counseling patients about weight loss is inconvenient. 11.5
Counseling patients about weight loss is professionally 65.0
gratifying.
Society is not doing enough to help alleviate obesity. 71.7
Physicians should be role models by setting an example as one 87.2
who maintains a normal weight.
I feel confident in prescribing weight loss programs. 47.5
Obesity is becoming more prevalent. 89.2
Obese patients appear to have more medical problems than non- 86.6
obese patients.
Alleviating childhood obesity is more important than alleviating 51.5
adulthood obesity.
Obesity is a significant cause of peer rejection. 89.2
With proper guidance most obese patients are able to lose 49.1
significant amounts of weight.
With proper guidance formerly obese patients are able to 61.6
maintain their weight.
n=l64
Questions 1-14 on questionnaire.

 

32

The respondents were then asked their level of agreement on if obesity was a risk factor
in acquiring these six different diseases. The following represents those who strongly
agreed; diabetes mellitus type H (85.5%), coronary heart disease (74.5%), stroke
(40.2%), osteoarthritis (36.4%), stress (27.3%), and colon cancer (24.8%). In the next
section of the questionnaire the respondents were also asked to “rate the possible
etiologies of obesity”. Ten options were listed using the format of minimal, minor,
moderate, and major role. To analyze this section of the survey moderate role and major
role were combined. The results are as follows; Almost all (98.8%) of the respondents
stated that sedentary lifestyle is the number one etiology of obesity; This is followed by
excessive calorie consumption at (93.9%), prevalence for junk food (80.3%), cultural
factors (79.3%), psychological problems (73%), lack of self control (69.7%), hormonal
problems (66.5%), Low socioeconomic status (48.4%), Negative peer pressure (45.1%),
and in utero—deleoped adipose hypercellularity (41.4%). The perceptions of the
etiologies of adulthood obesity are identified in Table 3.

For questions thirty-one through thirty-eight the respondents were asked on the
survey to indicate “where have you received most of your information on weight
control?” Eight sources were listed using the scale of minor role to major role. Using
moderate and major role responses the respondents ranked past experience (81.8%) as
the first source of information, followed by mass media (76.9%), medical school
(63.9%), extemship (62.4%), colleagues (57.6%), textbooks (56.0%),

workshops/seminars (27.5%) and medical journals (23.9%). See Table 4.

33

TABLE 3
All Respondents Perception of the Etiology of Obesity

 

 

Moderate Role.and Major Role
Excessive Calorie 9:9
Consumption
Sedeutary Lifestyle 98.8
Cultural Factors 79.3
Lack of Self Control 69.7
Psychological Problems 73 .0
Prevalence for Junk Food 80.5
Low Socioeconomic Status 48.4
Negative Peer Pressure 45.1
In Utero-developed Adipose 41.4
Hypercellularity
Hormonal Problems 66.5
n= 164

Questions 21-30 on questionnaire

34

 

TABLE 4
All Respondents Sources of Information About Obesity
Major Role
and Moderate
Role
%

Past Experience 81.8
Mass Media 76.9
Medical School 63.9
Externship 62.4
Colleagues 57.6
Textbooks 56.0
Workshops/ 27.5
Seminars
Medical Journals 23.9
n=164

 

Questions 31-38 on questionnaire

For questions thirty-nine through fifty-one the respondents were asked to select
which form of treatment they might recommend when counseling a patient about weight
loss. Almost a majority of students chose aerobics (93.9%) followed by seeing a
nutritionist/dietitian (87.9%) and, decreased calories consumption (76.4%) as the most

responded treatments. The other treatment results are reported in Table 5.

On questions fifty-two through fifty-seven, the respondents were asked Mary
Harris’s six true/false questions regarding their knowledge about obesity. The

respondents were split on the question that stated that “people who are overweight

35

generally eat more than people of average weight.” Approximately 50.9% chose true and

49.1% chose false. The correct answer to this question according to Mary Harris is false.

 

TABLE 5
All Respondents Recommendations for the Treatment of Obesity
YES %

Aerobics 93.9
Seeing a Nutritionist! Dietitian 87.9
Decreased Calorie Consumption 76.4
Behavior Modification Programs 71.5
Weight Watchers 23 .6
Seeing a Psychologist/Psychiatrist 20.0
TOPS (Take Pounds Off Sensibly) 19.4
Over Eaters Anonymous 17.6
Other 16.4
Diet Center 10.3
Specific Diet (i.e. Beverly Hills, 7.9
Grapefruit)
Camps for Overweight patients 6.7
Hypnosis 0.0

 

Questions 39-51 on the Questionnaire.

A majority (64.7%) of the students believed that “being even 10-15 pounds
overweight decreases one’s life expectancy.” The correct answer to this question is false.

The other items of the true/false questions were answered correctly with over 50% of the

36

respondents selecting the correct answer. The results and correct answers and identified

 

in Table 6.
TABLE 6
Osteopathic Students Knowledge About Obesity
True False
% “/-
People who are overweight generally eat more than people of average 50.9 49.1

weight. (F)

In westernized countries adults from a higher social class are less likely to 52.2 47.8
be overweight than adults of lower socioeconomic status. ('1')

There is an obese personality style which is characteristic of a majority of 26.1 73.9
overweight persons. (F)

Prolonged dieting causes a measurable reduction in the number of fat 4.4 95.6
cells the dieter has. (F)

It has been shown that genetic factors influence obesity in less than 10% 36.4 63.6
of all cases. (F)

Being even 10-15 pounds overweight decreases one’s life expectancy. (F) 64.7 35.3

 

Questions 52-57 on questionnaire

Analysis of Research Questions by Sex, Weight, and Class

Men and women were than compared using each of the different categories of
the questionnaire. Men and women did not differ on their beliefs about prescribing
weight loss programs and beliefs concerning obesity. The results are similar to the
overall Osteopathic medical student responses, see Table 2. Men (98.8%) and women
(98.8%) both stated that a sedentary lifestyle plays is a major etiology for obesity. Ninety-
three percent of women and 94% of men also stated that excessive calories plays a major

role in the etiology of obesity. When asked about risk factors associated with obesity

37

both men (88.8%) and women (83.8%) strongly agreed that obesity has a major role in
acquiring diabetes mellitus type 11. Approximately 76% of men and 74% of
women also strongly agreed that obesity can lead to coronary heart disease. However,

31.3% of men and 18.8% of women attributed obesity to colon cancer. See Table 7.

 

 

TABLE 7
Sex and Risk Factors
Coronary Diabetes Stroke Osteoarthritis Stress Colon
Heart Mellitus Cancer
Disease Type II
% % % “/0 % °/s
MEN
Strongly Agree 75.9 88.0 41.5 32.5 27.7 31.3
WQMEE
Strongly Agree 73.8 83.8 40.0 40.0 27.5 18.8

 

Questions 15-20 on questionnaire.

An analysis was done based on the respondents sex and where they received most
of their information from on obesity. Major role and moderate role responses were
combined for this section. Men ranked the following results as follows; past experience
83.2%, mass media 69.8%, medical school 68.6%, textbooks 60.3%, colleagues 57.9%,
extemship 51.9%, medical journal 25.3%, and workshop/seminars 20.5%. Women
ranked the following sources of information as; mass media 82%, past experience 76.7%,
medical school 50.6%, colleagues 48.1%, textbooks 41.8%, extemship 39.7%,

workshops/seminars 16.4% and medical journals 14.3%. See Table 8.

38

When asked about which treatments would men recommend for an obese patients
they chose aerobics 95.2%, seeing a nutritionist/dietitian 85.5%, decreased calorie
consumption 78.3%, behavior modification programs 65.1%, other 21.7%, seeing a
psychologist/psychiatrist 20.5%, Over Eaters Anonymous 18.], Weight Watchers 14.5,

TABLE 8
Men’s and Women’s Sources of Information About Obesity

 

MEN WOMEN
Major Role Major Role and
and Moderate Moderate Role
Role %
%
Medical Journals 25.3 14.3
Past Experience 83.2 76.7
Externship 5 1 .9 39. 7
Workshops/ 20.5 16.4
Seminars
Textbooks 60.3 41 .8
Colleagues 57.9 48. 1
Medical School 68.6 50.6
Mass Media 69.8 82.0
n=l64

 

Questions 31-38 on questionnaire.

TOPS 13.3%, diet center 10.8, specific diet 10.8%, hypnosis 6.0%, and camps for
overweight patients 6.0%. Women chose aerobics 93.8%, seeing a nutritionist/dietitian
90%, behavior modification 77.3%, and decreased calorie consumption 73.8%, and

Weight Watches 32.5%, TOPS 26.3%, seeing a psychologist/psychiatrist 20%. Over

39

Eaters Anonymous 17.5%, other 11.3%, diet center and hypnosis 10.0%, camps for

overweight patients 7.5%, and specific diets 5.0%. See Table 9.

TABLE 9
Men’s and Women’s Recommendations for the Treatment of Obesity.

 

% YES % YES
MEN WOMEN

Decreased Calorie Consumption 78.3 73.8
Seeing a Nutritionist! Dietitian 85.5 90.0
Weight Watchers 14.5 32.5
Aerobics 95.2 93.8
Behavior Modification Programs 65.1 77.5
Seeing a Psychologist/psychiatrist 20.5 20.0
Camps for Overweight patients 6.0 7.5
TOPS (Take Pounds 011' Sensibly) 13.3 26.3
Over Eaters Anonymous 18.1 17.5
Diet Center 10.8 10.0
Hypnosis 6.0 10.0
Specific Diet (i.e. Beverly Hills, 10.8 5.0
Grapefruit)
Other 21.7 11.3
n=l64

 

Questions 39—51 on questionnaire.

Men and women’s responses were also analyzed regarding knowledge about obesity.
Thirty-eight percent of the women believed that overweight people “eat more”, when
compared to 63% of men. Sixty-two percent of the women answered the question

correctly. The majority of both sexes (64.6% of men, 65.8% of women) answered “being

40

even 10-15 pounds overweight decreases one’s life expectancy” incorrectly. Over half of

both men and women answered the other four questions correctly. See Table 10.

 

TABLE 10
Men’s and Women’s Knowledge About Obesity
MEN WOMEN
% %
T F T F
People who are overweight generally eat more than people of 63.0 37.0 38.0 62.0
average weight.
(1")

In westernized countries adults from a higher social class are less 52.4 47.6 52.0 47.4
likely to be overweight than adults of lower socioeconomic status.

(T)

There is an obese personality style which is characteristic of a 27.5 72.5 24.7 75.3
majority of overweight persons. (F)

Prolonged dieting causes a measurable reduction in the number of 7.3 92.7 1.3 98.7
fat cells the dieter has. (F)

 

It has been shown that genetic factors influence obesity in less 36.7 63.3 36.0 64.0
than 10% of all cases. (F)
Being even 10-15 pounds overweight decreases one’s life 64.6 35.4 65.8 34.2
expectancy. (F)

n=164

Questions 52-57 on questionnaire.

The respondents were asked their height in feet and inches and their weight in
pounds. This was then converted to kilograms and meters to compute the Body Mass
Index (BMI) which is kg/m. The respondents were also asked how they perceived their
weight by choosing which weight classification they fit in. The three choices were
appropriate weight, too heavy, and too thin. When comparing the overall population with

their BMI, the students perception of their weight is in Table 11. The results of sex and

41

the respondents perception of their weight and BMI are shown in Table 12, and Table

13. The BMI classification is according to a BMI that is based on less than twenty is too

thin, between twenty and less than twenty-five is appropriate weight, and over twenty-

five is too heavy.

TABLE 11

Osteopathic Students Perception of Their Weight Compared to Their BMI.

 

Appropriate Too Heavy Too Thin n Missing
Weight
% % %
Osteopathic Students Perception of 60.4 32.1 7.4 157 7
Their Weight
BMI' 59.2 30.2 7.4 162 2

 

According to a BMI that is based on <20 Too Thin, >20-<25 Appropriate weight, >25 Too Heavy.

TABLE 12

Men’s Perception of Their Weight Compared to Their BMI.

 

 

MEN Appropriate Too Heavy Too n Missing
Weight Thin
% %
%
Osteopathic Students 60.9 31.7 7.3 82 2
Perception of Their Weight
BMI' 65.8 31.7 2.4 82 2

According to a BMI that is based on <20 Too Thin, >20-<25 Appropriate weight, >25 Too Heavy.

TABLE 13

Women’s Perception of Their Weight Compared to Their BMI.

WOMEN

 

 

Appropriate Too Heavy Too n Missin
Weight Thin g
% %
%
Osteopathic Students Perception 59.4 32.9 7 .5 79 1
of Their Weight
BMP 53.3 18.6 28.0 75 5

According to a BMI that is based on <20 Too Thin, >20-<25 Appropriate weight, >25 Too Heavy.

42

The attitudes and beliefs questions comparing weight found that the responses
were similar in distribution to overall respondents. The results from the role of obesity
in health risks are listed in Table 14. All of their respondents strongly agreed that
diabetes mellitus type H is the major risk factor followed by coronary heart disease.
However, appropriate weight chose osteoarthritis 37.8%, stroke 37.1%, stress 26.5%, and
colon cancer 24.5% as the remaining choices. Too heavy chose stroke 42.3%,
osteoarthritis 34.6%, stress 30.8%, and colon cancer 23.1%, as their remaining choices.

Too thin chose stroke 58.3%, colon cancer 33.3%, osteoarthritis 25%, and stress 16.7%.

 

TABLE 14
Weight and Risk Factors
Coronary Diabetes Stroke Osteoarthritis Stress Colon
Heart Mellitus Cancer
Disease Type II
% % % % % “/-
W
WEIQHI:

Strongly Agree 72.4 84.7 37.1 37.8 26.5 24.5
mm

Strongly Agree 82.7 86.5 42.3 34.6 30.8 23.1

199.1%

Strongly Agree 58.3 83.3 58.3 25.0 16.7 33.3
n=164

 

Questions 15-20 on questionnaire.

Questions about the etiology of obesity were also compared with the respondents

separated by weight classification of appropriate weight, too heavy, too thin, is reported

43

using the combine responses of moderate and major role. All of the weight classes
identified sedentary lifestyle as the major etiology, followed by excessive calorie
consumption, cultural factors, and prevalence for junk food. The too heavy (73.1%)
respondents believed that lack of self control contributed to obesity when compared to
appropriate weight (69.4%) and too thin (58.4%). Appropriate weight (74.2%) and too
heavy (80.8%) believed that psychological problems are a cause where as too thin
(41.6%) did not. Approximately fifty-five percent of the too heavy respondents and 42%
of the appropriate weight stated that negative peer pressure can contribute to obesity.
Only 25% of the too thin respondents felt peer pressure contributed to obesity. Twenty-
five percent of too thin felt that in utero developed hypercellularity is a cause of obesity
when compared to 40.4% of appropriate weight and 47.9% of too heavy respondents.
The etiologies and their percentages are identified in Table 15.

The responses for sources of information were combined using moderate and
major role. When comparing sources of information with weight almost a majority of
respondents for appropriate weight (81.5%) and too heavy (88.0%) chose past experience
as their main form of information, only 66.6% of too thin chose this item. Too thin
(75.8%) chose medical school as the first place they received their information from. All
of the weight classes chose mass media as their second choice, appropriate weight
75.0%, too heavy 82.4%, and too thin 72.8%. When asked about extemship, 71.1% of
too heavy felt this was an important source of information when compared to appropriate
weight 57.5%, and too thin 57.2%. Too thin (42.9%) felt that workshops/seminars were
an important source when compared to appropriate weight 26.6%, and too heavy 27.0%.

Over half of appropriate weight respondents (58.6%) gained their knowledge about

obesity from textbooks. Only 59.2% of too heavy, and 33.3% of too thin felt that

textbooks contributed to their knowledge base. See Table 16.

 

 

TABLE 15
Weight and Etiology of Obesity
Appropriate Too Heavy Too Thin
Weight
Moderate and Moderate and Moderate and
Major Role Major Role Major Role
% '/o %
Excessive Calorie 94.9 96.2 75.0
Consumption
Sedeutary Lifestyle 98.0 97.0 100.0
Cultural Factors 73.5 88.3 83.3
Lack of Self Control 69.4 73.1 58.4
Psychological Problems 74.2 80.8 41.6
Prevalence for Junk Food 78.4 86.6 75.0
Low Socioeconomic Status 48.0 48.1 58.4
Negative Peer Pressure 42.3 55.8 25.0
In Utero-developed Adipose 40.4 47.9 25.0
Hypercellularity
Hormonal Problems 61.5 84 63.7
n=164

Questions 21-30 on questionnaire.

TABLE 16

45

Weight and Sources of Information About Obesity

 

Appropriate Too Heavy Too Thin
Weight
Moderate and Moderate and Moderate and
Major Role Major Role Major Role
%
% %

Medical Journals 22.6 22.7 25.0
Past Experience 81.5 88.0 66.6
Externship 57.7 71.1 57.2
Workshops/ 26.6 27.0 42.9
Seminars
Textbooks 58.6 59.2 33.3
Colleagues 60.0 55.3 50.0
Medical School 59.7 68.6 75.8
Mass Media 75.0 82.4 72.8
n=164

 

Question 31-38 on questionnaire.

Treatment recommendations based on weight classifications showed that overall

the majority of the respondents regardless of weight chose aerobics, seeing a nutritionist!

dietitian, and decreased calorie consumption, and behavior modification. However, there

are three area of significant differences. Too heavy (32.7%) responded that they would

prescribe Weight Watchers more than appropriate weight (19.4%) and too thin (16.7%).

Too thin (41.7%) responded that they would prescribe seeing a psychologist/psychiatrist

more that appropriate weight (16.3%) and too heavy (23.1%). And lastly, too heavy

would use Over Eaters Anonymous (23.1%) more when compared to appropriate weight

(15.3%) and too thin (16.7%). See Table 17.

46

 

 

TABLE 17
Weight and Recommendations for the Treatment of Obesity
Appropriate Too Too
Weight Heavy Thin
YES % YES '/o YES %
Decreased Calorie Consumption 76.5 80.8 58.3
Seeing a Nutritionist/ Dietitian 86.7 88.5 91.7
Weight Watchers 19.4 32.7 16.7
Aerobics 91.8 98.1 100.0
Behavior Modification Programs 71.4 73.1 66.7
Seeing a Psychologist/Psychiatrist 16.3 23.1 41.7
Camps for Overweight patients 5.1 9.6 8.3
TOPS (Take Pounds Off Sensibly) 18.4 19.2 25.0
Over Eaters Anonymous 15.3 23.1 16.7
Diet Center 9.2 11.5 16.7
Hypnosis 9.2 5.8 16.7
Specific Diet (i.e. Beverly Hills, 8.2 5.8 16.7
Grapefruit)
Other 16.3 17.3 16.7
n=164

Question 39-51 on questionnaire.

The results on obesity knowledge, 52.1% of appropriate weight respondents chose
false correctly, while too heavy (59.9%) and too thin (58.3%) chose incorrectly for the
question about overweight people eat more than people of average weight Too thin was
divided equally on the question about social class and obesity. Fifty percent chose false
(incorrect) and 50% chose true ( correct) as the answer. A majority of all weight classes
stated that even being 10-15 pounds overweight decreases one’s life expectancy with

appropriate weight 67.7%, too heavy 57.1%, too thin 66.7%. See Table 18.

47

TABLE 18
Weight and Knowledge About Obesity

Appropriate Too Too
Weight Heavy Thin
O

 

 

% /o %

People who are overweight generally eat more than people oil T 47.9 56.9 58.3
average weight. (F)

F 52.1 43.1 41.7
In westernized countries adults from a higher social class T 50.5 54.0 50.0
are less likely to be overweight than adults of lower
socioeconomic status. (T)

F 49.5 46.0 50.0
There is an obese personality style which is characteristic of T 26.0 27.1 27.3
a majority of overweight persons. (F)

F 74.0 72.9 72.7
Prolonged dieting causes a measurable reduction in the T 5.3 0.0 16.7
number of fat cells the dieter has. (F)

F 94.7 100.0 83.3
It has been shown that genetic factors influence obesity in T 40.9 30.6 20.0
less than 10% of all cases. (F)

F 59.1 69.4 80.0
Being even 10-15 pounds overweight decreases one’s life T 67.7 57.1 66.7
expectancy. (F)

F 32.3 42.9 33.3
n=164

 

Question 52-57 on questionnaire.

An analysis between the class of 1998 and 1999 on attitudes and beliefs use the
combined responses of agree and strongly agree for the results. Analysis found that the
class of 1998 (78.9%) believed that society is not doing enough to help alleviate obesity
when compared to the class of 1999 (68.1%). The class of 1999 (52.2%) felt more
confident in prescribing weight loss programs compared to the class of 1998 (36.5%).
The class of 1998 (94.2%) responded that obese patients have more medical problems

than non—obese persons, 82% of the class of 1999 agreed with this. Approximately 62%

48

of the class of 1998, and 47% of the class of 1999 believed that alleviating childhood
obesity is more important that alleviation adulthood obesity. See Table 19.

The majority of both classes ranked diabetes mellitus, coronary heart disease, as
the two items strongly agreed upon when examining the risk factors of obesity.
However, the class of 1998 ranked osteoarthritis 51.0%, stroke 37.3%, and colon cancer
35.3% and stress 29.4%, as the remaining items. While the class of 1999 listed stroke
42.0%, osteoarthritis 30.1%, stress 26.5% and colon cancer 20.4%, as the remaining
items. See Table 20.

In this comparison of class and etiology moderate and major role responses were
combined. The respondents from the class of 1998 ranked sedentary lifestyle (98.1 %),
excessive calorie consumption (98.0%), cultural factors, and psychological problems
(82.4%), lack of self control (80.4%), and the prevalence for junk food (74.5%). The
class of 1999 ranked the top five etiologies as sedentary lifestyle (99.1%), excessive
calorie consummion (92.1%), prevalence for junk food (83.1%), cultural factors (77.7%),
and psychological problems(69.6%). See Table 21.

Sources of information and class were also compared combining moderate and
major role responses. For the class of 1998 (74.5%) past experience and the mass media
received the same amount of responses. Over half of the class of 1998 (68.7%) felt that
extemship was an important source of information. Approximately 65% of the class of
1998 received information from their colleagues and 62.7% from medical school. For
the class of 1999 past experience (81.1%) plays an important role as an information
source followed by mass media (76.5%), medical school 59.9%, textbooks 52.7%, and

colleagues 47.3%. Other items are identified in Table 22.

49

TABLE 19
Class and Attitudes and Beliefs About Obesity

 

 

Agree and Strongly Agree Agree and Strongly
Class of 1998 Agree
% Class of 1999
%
Maintaining normal weight is very 100.0 98.2
important to the health of the patient.
Physicians are obligated to counsel patients 98.1 97.3
about the risks of obesity.
Designing programs and counseling patients 75.0 69.0
is difficult.
Counseling patients about weight loss is 13.4 10.7
inconvenient.
Counseling patients about weight loss is 63.4 66.4
professionally gratifying.
Society is not doing enough to help alleviate 78.9 68.1
obesity.
Physicians should be role models by setting 88.3 86.6
an example as one who maintains a normal
weight.
I feel confident in prescribing weight loss 36.5 52.2
programs.
Obesity is becoming more prevalent. 86.5 90.2
Obese patients appear to have more medical 94.2 82.8
problems than non-obese patients.
Alleviating childhood obesity is more 61.6 46.5
important than alleviating adulthood
obesity.
Obesity is a significant cause of peer 94.3 87.6
rejection.
With proper guidance most obese patients 46.2 50.0
are able to lose significant amounts of
weight.
With proper guidance formerly obese 66.7 58.9
patients are able to maintain their weight.
n=164

Questions 1-14 on questionnaire.

50

 

TABLE 20
Class and Risk Factors
Coronary Diabetes Stroke Osteoarthriti Stress Colon
Heart Mellitus s Cancer
Disease Type II
'/o % % '/e 'lo %
W
Strongly Agree 70.6 94.1 37.3 51.0 29.4 35.3
W
Strongly Agree 76.1 81.4 42.0 30.1 26.5 20.4
n=164

 

Questions 15-20 on questionnaire.

 

TABLE 21
Class and Etiology of Obesity
Class of 1998 Class of 1999
Moderate and Moderate and
Major Role Major Role
% %
Excessive Calorie 98.0 92.1
Consumption
Sedeutary Lifestyle 98.1 99.1
Cultural Factors 82.4 77.7
Lack of Self Control 80.4 64.6
Psychological Problems 82.4 69.6
Prevalence for Junk Food 74.5 83.1
Low Socioeconomic Status 47.1 49.6
Negative Peer Pressure 49.0 43.7
In Utero-developed Adipose 47.0 39.3
Hypercellularity
Hormonal Problems 66.6 69.5

 

Questions 21-30 on questionnaire.

51

TABLE 22
Class and Sources of Information About Obesity

 

Class of 1998 Class of 1999
Moderate and Moderate and
Major Role Major Role
% %

Medical Journals 28.0 15.3
Past Experience 74.5 81.1
Externship 68.7 33.9
Workshops/ 25.5 14.3
Seminars
Textbooks 47.1 52.7
Colleagues 64.7 47.3
Medical School 62.7 59.9
Mass Media 74.5 76.5
n=164

 

Questions 31-38 on questionnaire.

When comparing class and knowledge about obesity 47.1% of 1998 and 52.3% of
1999 believed that overweight people “eat more” which is incorrect. See Table 23.
However, 71.4% of the class of 1998 and 61.3% of the class of 1999 believe that being

10-15 pounds overweight decreases life expectancy.

52

TABLE 23
Class and Knowledge About Obesity

CLASS OF CLASS OF
1998 1999
'/e "/e

 

T F T F
People who are overweight generally eat more than people of average 47.1 52.9 52.3 47.7
weight.
(F)

In westernized countries adults from a higher social class are less 49.0 51.0 54.1 45.9

likely to be overweight than adults of lower socioeconomic status.
('1')

There is an obese personality style which is characteristic of a 30.0 70.0 24.5 75.5
majority of overweight persons. (F)

Prolonged dieting causes a measurable reduction in the number of 6.0 94.0 3.7 96.3
fat cells the dieter has. (F)

It has been shown that genetic factors influence obesity in less than 34.0 66.0 36.9 63.1
10% of all cases. (F)

Being even 10-15 pounds overweight decreases one’s life expectancy. 71.4 28.6 61.3 38.7
(F)

n=164
Questions 52-57 on questionnaire.

 

CHAPTER V

Summary, Conclusions, and Recommendations

Summary

The purpose of this study and survey was to determine the attitudes and beliefs of
osteopathic medical students. Additionally, this study was concerned with the variables
of sex, weight, and class.

The obese patient will be a significant part of a physician’s patient population
and attitudes and beliefs of these physicians will be important factor in prevention and
treatment of obesity. A physician’s perception of their competence in prescribing weight
loss programs and their beliefs that obese patients are or are not able to lose significant
amounts of weight is very important to whether or not they will engage in counseling
obese patients to lose weight (Price, 1989). This study found that 31.9% of the
osteopathic medical students are planning to enter family practice and 15.1% into
internal medicine, and 15 .7% into a non-specified type of practice. This is an important
finding because primary care physicians will have the most contact with obese patients.

A majority of the osteopathic student believed that patients should maintain a
normal weight and that physicians are obligated to counsel patients about the risks of
obesity. In this study a majority of students disagreed that counseling patients about
weight loss is inconvenient, and that obese patients can keep the weight off with the
proper guidance. This shows that the students at this stage in their careers are willing to

take to time and have a desire to address the issue of weight management. However,

53

54

47 .5% of the students felt confident prescribing weight loss programs. This is probably
directly related to clinical experience.

Osteopathic medical students believed that obesity is a contributing factor in
acquiring diabetes mellitus, coronary heart disease, stroke, osteoarthritis, stress and colon
cancer. The National Institutes of Health Consensus Development Conference Statement
on Health Implications of Obesity, supports the belief that obesity is associated with
coronary heart disease, diabetes mellitus, and cancer (Burton, 1985). The students
believed diabetes over coronary heart disease to be the number one risk factor. When
asked about the etiologies of obesity the majority (98.8%) of the students stated that a
sedentary lifestyle is the main cause. This response could be attributed to the idea that
with inactivity comes increased weight (Dwyer, 1996). The respondents then were asked
where did they receive most of their information on weight control from. They ranked
past experience, mass media, medical school, extemship, and colleagues as their top five
choices. Even though the students have been exposed to a higher form of education
which includes physiology, biochemistry and anatomy, past experience and the media is
where they are acquiring their knowledge from. When asked to select a form of
treatment 93.9% chose aerobics as the main method of treatment. This may be related to
the response that obesity is caused by a sedentary lifestyle and that some type activity is
the most important treatment goal. The students selected seeing a nutritionist (87 .9%) as
their second choice. This could reflect the knowledge that a nutritionist can help with
behavior in food choices and preparation. In the past decreased calorie consumption was
the major form of treatment, for these students it was their third choice. This could

reflect a shift in treatment options which includes diet and exercise.

55

The respondents were asked true/false questions to test their knowledge about
obesity. A majority (50.9%) of the students stated that obese persons “eat more” than
average weight people. The correct answer to the question is that they do not eat more
and therefore it is false. This was surprising because the students did not find excessive
calories as the primary etiology for obesity and a decrease in calorie consumption was
not their first choice of treatment. This may reflect the students basing their response on
an incorrect stereotypes and not fact (Harris, 1983 ). The second question that was false
and a majority (64.7%) of the students marked true deals with life expectancy. These
students believed that being even 10-15 pounds overweight can decrease one’s life
expectancy. This is not a correct perception because risk factors that can cause a
premature death associated with obesity and weight gain are measured using the Body
Mass Index (BMI) and not by pounds. If a persons BMI which includes their height and
weight in kilograms is above 25 then they are at risk.

The first research question that was asked in this study was to see if there is a
difference between men and women osteopathic medical students in knowledge, attitudes
and beliefs about obesity in the areas of prescribing weight loss programs, health risks,
etiologies, information, and treatment recommendations. Surprisingly there was not a
significant difference between men and women about prescribing weight loss programs
and beliefs concerning obesity. Both men and women also agreed that sedentary lifestyle
and excessive calories consumption play a major role in obesity.

When asked about the risk factors, men and women both agreed on diabetes
mellitus, and coronary heart disease as the main risk factors. However, men (31.3%)

believed that colon cancer is the third most important factor and women spilt between

56

stroke (40%), and osteoarthritis (40%). This trend could be attributed to the fact that
obese men have higher mortality rates from cancers of the colon (Burton, 1985).

There were differences in where men and women acquire their information about
obesity from. Men gained most of their information from past experience, the mass
media, medical school. Women gained most of their information from the mass media,
past experience, medical school. This is an interesting finding although not surprising.
Men and women both agreed on which forms of treatments they might recommend to an
obese patient. Aerobics, seeing a nutritionist! dietitian, decreased calorie consumption,
and behavior modification were the top four choices. For men their fifih choice was other
and for women it was Weight Watchers. The selection of weight watchers may be
related to were women acquire most of their information from, the mass media.

The section on obesity knowledge proved more interesting results were more
women (62%) answered false to the “eat more” question when compared to the men who
believed that the statement was true (63%). This was the only group in the study that
answered the question correctly. However, a majority of both respondents answered
incorrectly to the life expectancy question, which is reflective of the overall student
population results.

The second research question asked wanted to see if there is a difference between
overweight and non-overweight osteopathic medical students in knowledge, attitudes and
beliefs about obesity in the areas of prescribing weight loss programs, health risks,
etiologies, information, and treatment recommendations. Analysis of the respondents
Body Mass Index (BMI) and perceived weight found that overall students were very

accurate with their own assessment their body image. However, when comparing sex

57

men were more accurate in their perception of their body image than women. More
women (32.9%) saw themselves as too heavy when compared to their BMI (18.6%). Six
women reported being too thin based on their perception, however, in comparison to the
BMI twenty-eight women were t00 thin. This finding is important because shows that
even though women perceived themselves as being of the appropriate weight they are
actually too thin. This may be suggestive of a negative body image that is perpetuated by
society on what weight is appropriate (Garner, 1996). The media provides information
about obesity, but it is often negative and this negativity is directed towards women.
Women are trying to achieve the unrealistic goals of weight and beauty that the media
has perpetuated in western society. In this pursuit for the “ideal” weight many women
acquire eating disorders. Researchers have found that women would rather lose ten to
fifieen pounds than achieve any other goal (Wolf, 1991).

On health risks associated with obesity all of the weight classes agreed that
diabetes mellitus and coronary heart disease are the two major factors. On etiology all of
the weight classes identified sedentary lifestyle as the major etiology followed by
excessive calorie consumption. Too heavy also attributed obesity to physiological
problems, lack of self control, and negative peer pressure when compared to the other
weight groups. These results might reflect too heavy’s past experiences with weight and
the personal problems they have experienced.

When comparing sources of information with weight almost a majority of
respondents for appropriate weight, and too heavy chose past experience as their main
form of information, however, too thin did not chose this item. This would make since

because the too thin population probably has never experienced being overweight. Too

 

 

58

thin chose medical school as the first place they receive their information from. All of
the weight class chose mass media as their second choice. When asked about extemship,
of too heavy felt this was an important source of information when compared to
appropriate weight and too thin. These findings are very interesting because it proved
that among the weight classes each uses different sources of information when it comes
to obesity. The use of past experience may not be a reliable source if biases and
unsubstantiated opinions have been formed. It is impossible to know the quality if the
respondents past experience (Price, 1989). On obesity knowledge over half of all weight
classes chose true incorrectly for the “eat more” question and true for the “life
expectancy” which was incorrect.

The third research question asked was to see if there is a difference between
second year and third year osteopathic medical students in knowledge, attitudes and
beliefs about obesity in the areas of prescribing weight loss programs, health risks,
etiologies, information, and treatment recommendations. An analysis between the class
of 1998 and 1999 on attitudes and beliefs use the combined responses of agree and
strongly agree for the results. Analysis found that the class of 1998 believed that society
is not doing enough to help alleviate obesity when compared to the class of 1999, this is
related to clinical experience and the patient population that the students are exposed to.
The class of 1999 felt more confident in prescribing weight loss programs compared to
the class of 1998. This finding was interesting. It would have been expected that the
class with more clinical experience would feel more confident dealing with obese
patients. This is important because this shows that between these two classes something

has happened that has changed their opinion and decreased their confidence. More

 

 

59

research needs to be done in this area. Approximately 62% of the class of 1998, and 47%
ofthe class of 1999 believed that alleviating childhood obesity is more important that
alleviation adulthood obesity. This can be correlated to patient management that the third
year students have experienced in the clinics. The longer a person is obese the more
medical problems they acquire. If obesity can be eliminated in childhood than those
future adults have the potential of having less medical problems, particularly those
associated with obesity.

For risk factors both classes agreed on the diabetes mellitus, and coronary heart
disease but differed on the third choice. The class of 1998 chose osteoarthritis and the
class of 1999 chose stroke for their top three. Clinical experience for the class of 1998
did not change their perception of the top two risk factors but it did affect how they
perceived the other choices.

A comparison of class and etiology found that the respondents from the class of
1998 ranked sedentary lifestyle, excessive calorie consumption, cultural factors,
psychological problems, lack of self control, and prevalence for junk food. The class of
1999 ranked the top five as sedentary lifestyle, excessive calorie consumption,
prevalence for junk food, cultural factors, and psychological problems. This difference
could be due to the involvement of the class of 1998 in taking histories and seeing how
different etiologies might play a role in obesity.

Sources of information and class were also compared combining moderate and
major role responses. For the class of 1998 past experience and the mass media received
the same amount of responses. Over half of the class of 1998 felt that extemship was an

important source of information. This is an interesting finding because it shows that

extemship is an important source of information for these students and that the quality of
this experience is important. For the class of 1999 past experience plays an important
role as an information source followed by mass media, medical school, and textbooks.
These findings were not surprising because at this stage due to lack of experience these
resources were appropriate.

The questions about obesity knowledge were consistent with the rest of the
findings with the classes answer the same two questions incorrectly as true. Based on
these questions in comparison to the class of 1999 clinical experience did not aide in

obesity lmowledge.

Conclusion

Many of my findings were encouraging and may of them were not. Osteopathic
students do believe that obesity is a serious health risk with serious consequences. It
was apparent that the osteopathic medical students understood the important issue of
normal weight for their patients and for themselves. It was also encouraging to see that
at this stage students have the desire and opinion that weight management is not
inconvenient. The students knowledge on obesity is based heavily from their past
experience and the mass media which tends to portrays overweight persons in a
stereotypical manner. This may explain some of discrepancies in some of the responses.
For example, that a sedentary lifestyle is the main contributor to obesity. Weight gain has
been attributed to culture, economic status, marriage, and educational attainment (Kahn,
1991). Even though the students have the education the stereotypical myths are still a

factor in their responses. Exercise is the main treatment of choice, maybe this is rooted

61

in the stereotype that all overweight people are lazy. There is a perception there that
obese persons are responsible for their condition (Crocker, 1993). However, two the
true/false questions on obesity knowledge that every group missed is disturbing. I have to
think that maybe the students believe these myths. In comparison to the Mary Harris’s
results the osteopathic medical students had a higher percentage of correct answers to her
questions. More research on myths and stereotypes on osteopathic students needs to be
done.

In conclusion, I feel that this study has shown that the attitudes and beliefs of
osteopathic students is very important in potential patient outcomes. There is a need for

more research about osteopathic medical students in the area of obesity.

Recommendations
The following recommendations grew out of the experience of completing this

study and questionnaire.

A. The use of a different type of likert scale might have added more significance to the
responses.

B. More questions on knowledge and myths would have been useful to get a more

accurate assessment.

C. More respondents fiom the class of 1998 would have beneficial to the overall results.

D. This research should be replicated at another osteopathic institution, in order to
extend and generalize that validity of findings to more than one population

E. This study and questionnaire should be replicated using allopathic students at other

institutions in comparison to the osteopathic students.

62

F. The academic curriculum should continue to strive to provide more information
about obesity.
G. A study on osteopathic medical students feelings about body image and how this

affects patient outcomes may need to be done.

APPENDIX

63

ZXIWPTETJIDI)(.!\

Michigan State University
College of OsteOpathic Medicine

Department of Osteopathic Surgical Specialties
HS. Tcitslbaurn, D. 0., Ph.D., M.P.H.

B-319 W.Fe¢ Hall 517-355-3361

E. Lansing, Michigan 48824-1315

Fax: 51 7432-1074

EMMY: tritelb@pilot. numedu

Apn|22.1997

Dear Colleagues:

My name is Candace Bradley, and I am currently a third year extended Osteopathic
medical student here at Michigan State University. 1 am also a Masters student in the process of
completing my thesis. My topic is “Attitudes and Beliefs of Second and Third Year Osteopathic
Students Regarding Obesity.‘ This study will use the class of 1998 and the class of 1999 as-the
sample of students here at Michigan State University.

Current studies have shown that during the time that we will be practicing medicine over
half of our patients will be overweight. This is a major health concern and how physicians feel
about the topic is an important factor in patient outcomes and treatment. Currently, there is little
research regarding Osteopathic medical students on the issue. Dr. Teitelbaum and I are hoping

that this research project will'contribute to the limited amount of studies done on Osteopathic
medical students.

This study is completely voluntary and you will indicate your voluntary agreement to
participate by completing and returning this questionnaire. You may choose not to participate at
all, or choose not to answer certain questions, or may discontinue the survey at any time. All
surveys are confidential and your answers will be anonymous.

Students who have taken the survey in a pilot study have taken about 10-15 minutes to
compiete it. instructions on where to return the survey will be given upon administration. Your
help and time in filling out the questionnaire would be appreciated. The results of this study will

be accessible upon its conclusion. It you have any concerns or questions about ”10 study YOU
can contact either of us via e-mail.

Thank you again for your time and consideration.

‘°T' "'2... 3.2,. was)

Candace Bradley H.S. Teltelbeum, 0.0. Ph.D.
MSU-COM 1999 Professor and Attending Physician
email: bredieymopliotmsuedu email: teitelbegpflotmsusdu

64

This questionnaire is intended to provide information on the attitudes and beliefs of Osteopathic
medical students on overnutrition or obesity. The responses are anonymous.

Using the scale to the right please circle the answer which best indicates your degree of agreement or
disagreement regarding each of these statements.

Part 1: Osteopathic medical students beliefs regarding prescribing weight programs for patients.

1 strongly disagree
2 Disagree

3 Agree

4 Strongly Agree
5 Don’t know

1. Maintaining normal weight is very important to the health of the patient. 1 2 3 4 5

2. Physicians are obligated to counsel patients that are obese concerning the 1 2 3 '4 5
health risks of obesity.

3. Designing programs and counseling patients about weight loss is 1 2 3 4 5
difiicult.

4. Counseling patients about wieght loss is inconvenient. 1 2 3 4 5
5. Counseling patients about weight loss is professionally gratifying. 1 2 3 4 5
6. Society is not doing enough to help alleviate obesity. 1 2 3 4 5
7. Physicians should be role models by setting an example as one who

maintains a normal weight. 1 2 3 4 5
8. I feel competent in prescribing weight loss programs. 1 2 3 4 5

Part 2: Osteopathic medical students’ beliefs concerning obesity.

9. Obesity is becoming more prevalent. 1 2 3 4 5

10. Obese patients appear to have more medical problems than nonobese 1 2 3 4 5
patients.

11. Alleviating childhood obesity is more important to patient health than 1 2 3 4 5
alleviating obesity in adulthood.

12. Obesity is a significant cause of peer rejection. 1 2 3 4 5

13. With proper guidance most obese patients are able to lose significant L 2 3 4 5
amounts of weight.

14. With proper guidance formerly obese are able to maintain their 1 2 3 4 5

weight.

65

Part 3: Role of obesity in health risks.
Below is a series of medical conditions. Please indicate your level of agreement or disagreement on whether
or not obesity is a risk factor in acquiring these condtions.

l Strongly Disagree
2 Disagree

3 Agree

4 Strongly Agree

5 Don’t Know

15. Coronary Heart Disease W
16. Diabetes Mellitus type II 1 2 3 4 5
17. Stroke 1 2 3 4 5
18. Osteoarthiritis 1 2 3 ~4 5
19. Stress 1 2 3 4 5
20. Colon Cancer 1 2 3 4 5

Part 4: Osteopathic medical students perceptions of the etiology of obesity. Please rate these
possible etiologies according to the following scale.

1 Minimal Factor
2 Minor Factor

3 Moderate Factor
4 Major Factor

5 No Role

Possible Etiologies:

21. Excessive calorie consumption 1 2 3 4 5
22. Sedeutary lifestyles 1 2 3 4 5
23. Cultural factors 1 2 3 4 5
24. Lack of self control 1 2 3 4 5
25. Psychological problems 1 2 3 4 5
26. Prevalence for junk food 1 2 3 4 5
27. Low socioeconomic status 1 2 3 4 5
28. Negative peer pressure 1 2 3 4 5

29. In utero—developed adipose hypercellarity 1 2 3 4 5

30. Hormoneproblems l 2 3 4 5

66

Part 5: Weight loss programs for patients. Please indicate where you have received most of your
information on weight control.

1 Minor Role
2 Minimal Role
3 Moderate Role

4 Major Role

5 No Rule
31. Medical journals 1 2 3 4 5
32. Past experience 1 2 3 4 5
33. Externships 1 2 3 4 5
34. Workshops/seminars 1 2 3 _4 5
3S. Textbooks l 2 3 4 5
36. Colleagues 1 2 3 4 5
37. Medical school classes 1 2 3 4 5
38. Mass media 1 2 3 4 5

Part 6: Ifyou were counseling a patient about weight loss, which of the following would you
recommend? Select the response that best fits your choice by placing an X or check in the space
provided. You can choose more than one response.

39. Decreased calorie consumption

40. Seeing a dietitian/nutritionist

41. Weight Watchers

42. Aerobic Exercise

43. Behavior modification programs

44. Seeing a psychologist/psychiatrist

45. Camps for overweight patients

46. TOPS (Take Pounds Ofl‘ Sensibly)

47. Overeaters Anonymous

48. Diet center

49. Hypnosis

50. Specific diet (i.e. Pritikin, Beverly Hills, grapefiuit, etc.)
51. Other: Specify

67

Part 7: Knowledge about obesity. Please respond to the following statements about obesity by
circling true or false.

52. People who are overweight generally eat more that people of average weight. T F

53. In westernized countries adults from a higher social class are less likely to be T F
overweight than adults of lower socioeconomic status.

54. There is an obese personality style which is characteristic of a majority of T F
overweight people.

55. Prolonged dieting causes a measurable reduction in the number of fat cells the T F
dieter has.

56. It has been shown that genetic factors influence obesity in less than 10% of all T F
cases.

57. Being even 10-15 pounds over weight decreases one’s life expectancy. T F

Part 7: Personal Background:
Now we would like to find out something about you. Please answer the following questions by filling

in the blanks or checking the box that applies.
58. Year born 59. Sex: male Female

60. Weight __pounds 61. Height ft inches

Do you consider yourself:

62. Appropriate weight Too Heavy Too thin
63. Ethnic Background 64. Indicate which term will describe the
scope of your future practice.
African American __
Asian/ Pacific Islander Medicine Surgery
Caucasian General F arnily Practice General
Latino/ Hispanic Internal Medicine Specialty
Native American Pediatrics Subspecialty
Other Obstetrics/Gynecology
Psychiatry Medical Research
Subspecialty of Internal
Medicine __ Other __
Other
65. Classification
Class of 1998
Class of 1999

Thank you for you time.

LIST OF REFERENCES

LIST OF REFERENCES

Adams, C. Smith, N. The relationship of obesity to the frequency of pelvic examination:
do physicians and patients attitudes make a difference? Womens ’ Health.
1993;20:45-57.

Atkinson, Richard. Proposed standard for judging the success of the treatment of
obesity. Annals of Internal Medicine 119, 677-680

Balcazar, Hector. Overweight among Mexican-Americans and its relationship to lifestyle
behavior risk factors. Journal of Community Health. 18, 55-67

Barr, Susan. The obesity epidemic. Shape, October, 1996, 115-121

Bellack, A.S. Hersen, M., Kazdin, A.E. International Handbook of Behavior
Modification and Therapy (2nd ed) New York: Plenum Press, 1990

Ben-Tovim, David. Walker, Kay. The influence of age and weight on women's body
attitudes as measured by the body attitudes questionnaire (BAQ). Journal of .
Psychosomatic Research. 1994;38:477-481

Blackburn, George L. Comparison of medically supervised and unsupervised approaches
to weight loss and control. Annals of Internal Medicine, 1993;119:714-718

Blumberg, P. Mellis, LP. Medical students’ attitudes towards the obese and the
morbidly obese. International Journal for Eating Disorders. 1980;4: 169-75.

Bouchard, Claude. Current understanding of the etiology of obesity: genetic and
nongenetic factors. American Journal of Clinical Nutrition, 1991 ,53: 1561 S-SS

Bouvier, Leon. Grant, Lindsey. How many Americans? Population, immigration, and
the environment. Sierra Club Books. San Franciso. 1994

Burton BT. Health implications of obesity: an NIH consensus development conference.
International Journal of Obesity. 1985;92155-69.

Bray, GA. Obesity in America. US. Department of Health Education, and Welfare.
1979.

Cade, J. O’Connell, S. Management of weigh problems and obesity: knowledge,

attitudes and current practice of general practitioners. British Journal of General
Practice. 1991;41:147-150.

68

69

Conway, Joan. Ethnicity and energy stores. American Journal of Clinical Nutrition,
1995:62210678-718

Crocker, Jennifer. Comwell, Beth. Major, Brenda. The stigma of overweight: affective
consequences of attributional ambiguity. Journal of Personality and Social
Psychology. 1993;64:60-70

Drell, WK. Countertransference and the obese patient American Journal of
Psychotherapy. 1988;42:77-85.

Foreyt, John. Ramirez, Amelie. Cousins, J ennifer,. Cuidando El Corazon- a weight
reduction intervention for Mexican American American Journal of Clinical
Nutrition 1991;53:16398-41S

Fosler, Scott. Alonso, William. Kern, Rosemary. Demographic change and the
American future. University of Pittburg Press. 1990

Garner, David. Wooley, Susan. Confronting the failure of behavioral and dietary
treatments for obesity. Clinical Psychology Review 1991 ;l 11729-780

Gevitz, Norman. The D. 0. ’s: Osteopathic medicine in America. The Johns Hopkins
University Press. Baltimore. 1982

Gortmaker, Steven. Must, Aviva, et al. Social and economic consequences of overweight
in adolescence and young adulthood. New England Journal of Medicine
1993;329:1008-12

Haffner, Steven. Stern, Michael. Predictors of obesity in Mexican Americans.
American Journal of Clinical Nutrition, 1991;53: 15718-68

Hall, Sharon K. Cousins, Jennifer H., et a1. Self -concept and perceptions of
attractiveness and body size among Mexican-American mothers and daughters.
International Journal of Obesity 1991;15:567-575

Harris, Mary B. Eating Habits, Restraint, Knowledge and Attitudes Toward Obesity.
International Journal of Obesity 1983;72271-286

Harris, Mary B. Waschull, Stefanie, et al. Feeling Fat: Motivations, Knowledge, and
Attitudes of Overweight Women and Men Psychological Reports
1990;67:1191-1202

Horm, John, Anderson, Kay. Who in America is trying to lose weight. Annals of
Internal Medicine 1993;119(7 pt 2):672-676

70

Jackson, Yvonne M., Proulx Joanne M., et a1. Obesity prevention American Society for
Clinical Nutrition 199 1 ;5 3: 16258-308

Jeffery, Robert W. Minnesota Studies on Community-based Approaches to Weight Loss
and Control. Annals of Internal Medicine 1993;119(7 pt 2):719-721

Jeffery, Robert W. Populations perspectives on the prevention and treatment of obesity
in minority populations. American Journal of Clinical Nutrition
1991;53:16218-48

Jones, Bob. The Diflerence a D. 0. Makes. Times-Journal Publishing Company.
Oklahoma City, Oklahoma. 1978.

Kahn, Henry S. Williamson David F. Is race associated with weight change in US adults
after adjustment for income, education, and marital factors? American Journal of
Clinical Nutrition 1991;53: 15668-708

Kahn Henry S. Williamson, David F., et a1. Race and Weight Change in US Women:
The Roles of Socioeconomic and Marital Status American Journal of Public
Health, 1991,81: 319-323

Kumanyika, Shiriki K. Special Issues Regarding Obesity in Minority Populations.
Annals of Internal Medicine, 1993;119:(7 pt 2):650-654

Kumanyika, Shiriki K. Obarzanek Eva. Weight-loss experience of black and white
participants in NHLBI-sponsored clinical trials. American Journal of Clinical
Nutrition, 1991;53:16318-88

Levy, Alan S. Heaton Alan W., Weight Control Practices of US. Adults Trying to Lose
Weight. Annals of Internal Medicine, 1993;119(7 pt 2):661-666

Maddox GL. Lieberman, MA. Overweight as a social disabiltiy with medical
implications. Journal of Medical Education. 1969;44:214-220

Macfarlane, C.M. Obesity in perspective. SAM], 1986;69:185-190

Malina, RM. Ethinic variation in the prevalence of obesity in North American children
and youth. Critical Review of Food Science. 1993;33:389-396.

McGinnis, Michael J. Foege, William H. Actual Causes of Death in the United States.
JAMA, 1993;270:2207-2212

McGinnis, Michael J. Ballard-Barbash, Rachel M. Obesity in minority populations:
policy implications of research. American Journal of Clinical Nutrition,
1991;53:15128-48

7]

Murphree, Duaine. Patient Attitudes Toward Physician Treatment of Obesity. Journal
of Family Practice, 1994;38:45-48

Najman, JM. Arnold, L. An initial explanitory model of medical students preferences
for patient types. Journal of Medical Education. 1984;18:249-254.

Najman, JM, Isaacs, G. Teaching sociology to medical students. Journal of Medical
Education. 1978;12:406-412.

Pawson, Ivan G. Martorell, Reynaldo. Prevalence of overweight and obesity in US
Hispanic populations. American Journal of Clinical Nutrition, 1991;53:15228-88

Pi-Sunyer, F. Xavier. Medical Hazards of Obesity. Annals of Internal Medicine,
1993;119(7 pt 2):655-660

Price, James H., Desmond, Sharon M., et al. Family Practice Physicians’ Beliefs,
Attitudes, and Practices Regarding Obesity. American Journal of Preventative
Medicine, 1987;3:339-45

Roth, David. Feelings of F atness Questionnaire: A Measure of the Cross-Situational
Variability of Body Experience. International Journal of Eating Disorders,
1993;14:349-358

Russell, Carl M.. Williamson, David F., et a]. Can the Year 2000 objective for reducing
overweight in the United States be reached? a simulation study of the required
changes in body weight. International Journal of Obesity, 1995;19:149-153

Segel Jill 8. McAnamey, Elizabeth R. Adolescent Pregnancy and Subsequent Obesity in
African-American Girls. Journal of Adolescent Health, 1994;15:491-494

Schneider, Karen S. Levitt, Shelley, et a1. Mission Impossible. People, 1996;63-74

Sichieri, R. Everhart, JE. Relative weight classifications in the assement of underwieght
and overweight in the United States. International Journal of Obesity and Related
Metabolic Disorders. 1992;16:303-12.

Stavig, G. Leonard, A. Indices of relative body weight and ideal weight charts. Jounral
of Chronic Disease. 1984;37:255-262.

Stevens, June, Kumanyika, Shiriki, et a1. Attitudes toward Body Size and Dieting:
Differences between Elderly Black and White Women. American Journal of
Public Health, 1994;84:1322-1325

Stunkard Albert J. Current Views on Obesity. American Journal of Medicine,
1996; 100:230-235

72

Wattenberg, Ben. T he first universal nation. The Free Press. New York. 1991
WieseJ-IJ. Wilson, JF. Obesity stigma reduction in medical students. International
Journal of Obesity and Related Metabolic Disorders. 1992;16:859-868.

Williamson, David F. Descriptive Epidemiology of Body Weight and Weight Change in
US. Adults. Annals of Internal Medicine, 1993;119(7 pt 2):646-649

Williamson, David F. Kahn, Henry 8., et al. The IO-y incidence of obesity and major
weight gain in black and white US women aged 30-55 y. American Society for
Clinical Nutrition, 1991;53:15158-88

Wright, Erma J. Whitehead, Tony L. Perceptions of Body Size and Obesity: A Selected
Review of the Literature. Journal of Community Health, 1987;12:117-129

Wooley, Susan C. Garner, David M. Obesity treatment: The high cost of false hope.
Journal of the American Dietetic Association, 1991;91:1248-1251

Wolf, Naomi. The Beauty Myth. William Morrow and Company. New York. 1991.

Yanovski,8Z. A practical approach to treatment of the obese patient. Archives of Family
Medicine. l993;2:309-316.

31293017663182