Despite the high prevalence of obesity and its associated harmful health effects  physicians frequently fail to counsel patients about nutrition and weight management [3–7] and frequently report and demonstrate a lack of training and competence in obesity management [8–13]. Clinicians who learn good obesity screening and counseling practices in residency are more likely to report that they always discuss diet or exercise with obese patients . Therefore training of physicians has the potential to impact patient outcomes.
Attitudes, or "individual's positive or negative evaluation of performing a behavior " may also contribute to insufficient or ineffective counseling practices. Major theories predicting practice behavior postulate that attitudes are important influences on the decision to engage in a defined behavior [14, 15]. Attitudes can serve to motivate a provider to take action and encourage a physician to feel capable of tackling a particular behavior (e.g., self-efficacy, perceived behavior control ). Indeed, higher self efficacy in delivering preventive care services was predictive of preventive counseling in pediatricians . Attitudes also may instill in a physician the belief that the behavior in question is worth doing because it will produce the intended outcomes (e.g., perceived benefits, outcome expectancies ).
Thus, physicians' attitudes about obesity may affect their practice. Studies have shown that physicians' attitudes toward obese patients can be negative, e.g., some primary care physicians rate obese patients negatively with respect to their likelihood of following advice, believe that obese patients are less likely to benefit from counseling, and report less desire to help obese patients , and therefore may decrease physicians' motivation to counsel such patients. Even health professionals specializing in obesity have implicit anti-fat bias and are more likely to automatically associate 'fat people' with negative stereotypes than 'thin people' [19, 20]. Physicians' attitudes and beliefs about their own general efficacy in treating obesity may also influence their treatment of patients. In one study, physicians rated obesity treatment as less effective than therapies for 9 out of 10 chronic conditions, and only 14% agreed that they were usually successful in helping obese patients lose weight . In another study, 31% of internal medicine residents believed that treating obesity is futile and only 44% felt qualified to treat obese patients . We have found no studies of direct impact of negative physician attitudes on obesity care.
While attitudes are thought to influence physician behavior with regards to obesity counseling, we know very little about how these attitudes are formed or influenced. Social cognitive theory and the theory of planned behavior suggest that competence (skills or prior performance) is an important influence on attitudes [14, 15]. A few studies have tested this hypothesis in obesity with mixed results: one study showed that perceived competency was correlated with comfort level in treating pediatric obesity and the belief that obesity is a treatable condition , while another study did not find any link between knowledge (an essential determinant of competence) and attitudes .
Models of behavior change also suggest that social and environmental factors play an important part in shaping attitudes. For physicians these include individual physician characteristics (e.g., age, gender) [20, 23, 24], training (e.g., specialty, when trained, exposure to role models). Practice contexts (e.g., type of patients seen, public vs. private setting, inpatient vs. outpatient) may also influence attitudes. With the exception of physician bias [19, 26], few studies have characterized physicians' attitudes about obesity with regards to gender, specialty, training and practice characteristics. Further, while several studies have described individual physicians' attitudes about obesity [22, 27–29], none have characterized how these attitudes relate to each other.
Additional studies are needed to elucidate the relative contribution of individual competence, physician, training, and practice variables on attitude formation. This is necessary in order to design more carefully targeted interventions and ultimately to be able to assess the impact of these attitudes on actual physician practice and patient outcomes.
As part of a needs assessment for a faculty development project to improve obesity care, we surveyed physician faculty members about their attitudes, obesity counseling competency (including report of percentage of their obese patients who lose weight), training, and practice characteristics. The first aim of this study was to understand and classify the nature of physician attitudes regarding obesity and examine how they differ by specialty. The second aim of this study was to better understand how competency in obesity counseling, physician characteristics, training, and practice characteristics are related to attitudes. The final aim was to explore the relative association of each of these on physician attitudes.