What this is
- This research examines changes in the practices of Italian endocrinologists regarding obesity management.
- A survey was conducted to assess attitudes and treatment approaches following educational initiatives.
- Findings indicate an increase in the recognition of obesity as a significant health issue among endocrinologists.
Essence
- Italian endocrinologists are increasingly recognizing and managing obesity, with a notable rise in approaches. Educational initiatives have contributed to improved attitudes and practices in obesity care.
Key takeaways
- 43.4% of endocrinologists reported that over 35% of their patients have obesity, up from 37.8% in 2022. This indicates a growing awareness of obesity prevalence in clinical practice.
- The proportion of endocrinologists managing obesity increased from 42.6% to 45.5%. This reflects a slight shift towards more proactive management of obesity among healthcare providers.
- Liraglutide usage rose from 10% to 25% among suitable patients, indicating a growing acceptance of pharmacological treatments for obesity.
Caveats
- The response rate was 16.6%, which may not fully represent all endocrinologists. This could limit the generalizability of the findings.
- The survey was conducted before the approval of new anti-obesity drugs, which may have influenced responses regarding treatment options.
- Despite increased awareness, remains underutilized, indicating a gap between knowledge and practice.
Definitions
- pharmacological treatment: Use of medications to manage obesity, often in conjunction with lifestyle changes.
Simplified
Introduction
The increasing prevalence of overweight and obesity has become a global health crisis, raising serious concerns worldwide. In 2021, an estimated 1.00 billion adult males and 1.11 billion adult females had overweight or obesity (1). From 1990 to 2021, the global deaths and disability adjusted life years (DALYs) attributable to high body mass index (BMI) increased more than 2.5-fold for females and males (2), with cardiovascular disease and the composite of diabetes and kidney diseases representing the two primary contributors to high BMI-attributable DALYs.
Recent estimates from the World Health Organization (WHO) indicate that overweight and obesity affect almost 60% of adults and nearly one in three children (29% of boys and 27% of girls) in the WHO European Region (3). In Italy, data from the National Institute of Statistics show that between 2001 and 2010, the number of individuals with overweight increased by approximately two million, while those with obesity rose by over one million. By 2023, over 23 million Italian adults, accounting for 46.3% of the population, were classified as overweight or obese (17.0 million with overweight and 5.8 million with obesity) (4).
Excess weight imposes a significant clinical, social, and economic burden due to its association with numerous health conditions, including diabetes, cardiovascular diseases, respiratory disorders, certain cancers, and osteoarticular diseases (5). Additionally, individuals with obesity often face stigma, discrimination, and a decline in both mental well-being and health-related quality of life (6).
Given these challenges, obesity should be acknowledged by healthcare providers and insurers as a chronic condition requiring care, support, and follow-up (7).
Despite the existence of evidence-based guidelines, including the recent Italian guidelines (8 –14), the rising prevalence of obesity indicates that these recommendations are not effectively implemented. Suboptimal care for individuals with obesity is widely reported (15 –18), with low rates of diagnosis, documentation, and management (19, 20), as well as insufficient knowledge of obesity treatment guidelines among healthcare professionals (21). Additionally, few individuals with obesity receive weight-loss counseling, and only about a quarter of those counseled have a follow-up appointment scheduled to monitor their progress (19, 21).
Research also highlights significant variability in the use of pharmacological and surgical interventions (19, 22), suggesting a lack of familiarity with treatment initiation and referral criteria. Misconceptions regarding the safety and effectiveness of available weight-loss medications and bariatric procedures further contribute to the inconsistent management of obesity (17, 23). Clinical endocrinologists play a crucial role in identifying, evaluating, and managing obesity, given the high proportion of patients with excess body weight in their care. A previous survey conducted by the Italian Association of Clinical Endocrinologists (AME) in 2022 documented that endocrinologists regularly encounter patients with obesity, yet they often do not address the problem or manage it (24). Furthermore, the survey showed that, despite the current availability of safe and effective anti-obesity medications, with even more efficacious options emerging, pharmacological treatment was rarely prescribed by most participants, who perceived several barriers to effective obesity management. Following the survey, AME launched a series of educational activities for its members focused on the management and care of obesity by endocrinologists.
The current study aimed to assess whether these educational activities, along with increasing body of evidence supporting the safety and effectiveness of new anti-obesity drugs, particularly glucagon-like peptide 1 (GLP1) receptor agonists, had an impact on practices and attitudes of Italian endocrinologists regarding care of people with obesity. At the time of the survey, semaglutide and tirzepatide had not yet been approved for commercial use in Italy for the treatment of obesity or overweight with complications (BMI >27).
Materials and methods
This study was a cross-sectional survey conducted among endocrinologists who are members of AME. Participants were invited to complete an online multiple-choice questionnaire, which remained open for four weeks. The survey was created using LimeSurvey, an open-access platform offering various question templates.
A survey link was emailed to 2560 endocrinologists, with weekly reminders sent to non-respondents to encourage participation. Participation was voluntary, with no compensation provided, and all responses were anonymous. The survey data was collected and securely stored electronically by the survey platform, accessible only via a password-protected system. The survey system automatically prevented multiple submissions from the same IP address.
The questionnaire aimed to evaluate several aspects of endocrinologists' approach to obesity management, including:
The questionnaire also collected demographic information about participants, including their sex, age, years of practice, primary areas of specialization, type and setting of their practice, and whether their facility had a dedicated obesity specialist or unit.
Statistical analysis
Continuous data are presented as the median with interquartile range (IQR), while categorical data are expressed as percentages.
All statistical analyses were conducted using SPSS software, version 23.0 (IBM, Armonk, NY, USA).
Results
Characteristics of respondents
A total of 424 out of 2560 endocrinologists participated in the survey, resulting in a response rate of 16.6%. The characteristics of the participants in the 2024 survey and those who took part in the 2022 survey are reported in Table 1. Almost two-thirds of participants were females. The sample was well-balanced in terms of age groups and years of practice. The primary areas of practice included thyroid disorders, general endocrinology and diabetes mellitus. Additionally, 32.5% of respondents identified nutrition and obesity as a key area of interest.
Almost half of the surveyed endocrinologists worked in a public hospital setting, with 17.0% affiliated with a university and 30.9% in non-affiliated hospitals. The remaining participants practiced in public (19.1%) or private (30.4%) outpatient clinics. A dedicated obesity specialist or unit was present in the practice setting of 49.3% of the participants.
Compared to the participants in the 2022 survey, the sample involved in the new survey showed a lower prevalence of endocrinologists under the age of 30 and a higher prevalence of specialists who were older and had longer work experience in the endocrine-metabolic field.
| Characteristics | 2022 | 2024 |
|---|---|---|
| N (%) | N (%) | |
| Gender | ||
| Male | 218 (40.2%) | 164 (38.7%) |
| Female | 318 (58.7%) | 256 (60.4%) |
| Not reported | 6 (1.1%) | 4 (0.9%) |
| Age (years) | ||
| <30 | 115 (21.5%) | 27 (6.4%) |
| 30-40 | 97 (18.2%) | 102 (24.1%) |
| 41-50 | 135 (25.3%) | 72 (17.0%) |
| 51-60 | 125 (23.4%) | 82 (19.3%) |
| 61-70 | 18 (3.4%) | 95 (22.4%) |
| >70 | 37 (6.9%) | 45 (10.6%) |
| Not reported | 7 (1.3%) | 1 (0.2%) |
| Years of practice in the endocrinologic/metabolic field | ||
| <5 | 65 (12.2%) | 61 (14.4%) |
| 5-10 | 72 (13.5%) | 77 (18.2%) |
| 11-20 | 121 (22.7%) | 79 (18.6%) |
| 21-30 | 110 (20.6%) | 75 (17.7%) |
| 31-40 | 111 (20.8%) | 83 (19.6%) |
| >40 | 35 (6.6%) | 48 (11.3%) |
| Not reported | 20 (3.7%) | 1 (0.2%) |
| Main areas of practice* | ||
| Thyroid | 349 (65.4%) | 267 (63.0%) |
| General endocrinology | 284 (53.2%) | 231 (54.5%) |
| Diabetes mellitus | 253 (47.4%) | 234 (55.2%) |
| Nutrition/obesity | 157 (29.4%) | 138 (32.5%) |
| Osteoporosis | 90 (16.9%) | 88 (20.8%) |
| Pituitary gland | 51 (9.6%) | 32 (7.5%) |
| Andrology | 24 (4.5%) | 26 (6.1%) |
| Adrenal gland | 39 (7.3%) | 23 (5.4%) |
| Mineral metabolism | 29 (5.4%) | 22 (5.2%) |
| Oncological endocrinology | 42 (7.9%) | 19 (4.5%) |
| Pediatric endocrinology | 16 (3.0%) | 13 (3.1%) |
| Reproduction | 12 (2.2%) | 9 (2.1%) |
| Endocrinological surgery | 4 (0.7%) | 1 (0.2%) |
| Kind of practice | ||
| Private practice | 164 (30.7%) | 148 (34.9%) |
| Hospital | 206 (38.6%) | 132 (31.1%) |
| Outpatient clinic | 79 (14.8%) | 81 (19.1%) |
| Resident doctor | 30 (5.6%) | 37 (8.7%) |
| University | 16 (3.0%) | 11 (2.6%) |
| Setting of practice | ||
| Non-university hospital | 188 (35.2%) | 131 (30.9%) |
| University hospital | 96 (18.0%) | 72 (17.0%) |
| Public outpatient clinic | 89 (16.7%) | 81 (19.1%) |
| Private outpatient clinic | 129 (24.2%) | 129 (30.4%) |
| Other | 32 (6.0%) | 2 (0.5%) |
| Availability in the structure of a specialist or unit dedicated to obesity | ||
| Yes | 278 (52.1%) | 209 (49.3%) |
| No | 210 (39.3%) | 194 (45.8%) |
| Don't know | 13 (2.4%) | 12 (2.8%) |
| Not reported | 33 (6.2%) | 9 (2.1%) |
Management of obesity
Responses to this section of the survey in comparison with those of the 2022 survey are summarized in Table 2. Among participants, 39.6% reported that 20% to 35% of the patients they see each month have obesity, while 43.4% indicated even higher percentages, compared to 37.8% in the previous survey.
No major differences between the two surveys emerged regarding the proportion of patients with obesity seeking care for another endocrinological issue in whom obesity was addressed. On the other hand, the proportion of endocrinologists who reported managing obesity themselves, either independently or as part of a dedicated team, slightly increased from 42.6% to 45.5%.
Beliefs regarding the role of ketogenic diet and physical activity did not change with respect to the 2022 survey. In particular, a large majority of respondents found the ketogenic diet useful, particularly as an initial approach following the failure of lifestyle interventions (39.2%), or as bridge therapy before bariatric surgery (28.5%).
The most frequently recommended types of exercise included individualized programs tailored to the patient's needs (43.6%) and aerobic exercises (37.0%).
Psychological support was viewed as a valuable component in obesity management. Among participants, 38.0% believed it should be offered to all patients with obesity, while an additional 30.2% recommended it in at least half of the cases. No major changes were evidenced with respect to the previous survey.
| Item | 2022 survey | 2024 survey |
|---|---|---|
| How many patients, among those you see in a month, have obesity? | ||
| <20% | 17.5% | 14.4% |
| 20-35% | 44.7% | 39.6% |
| 36-50% | 24.9% | 31.1% |
| >50% | 12.9% | 12.3% |
| During the visit of a patient with obesity who came for another endocrinological problem, how often is the problem of obesity addressed? | ||
| Never | 1.8% | 2.8% |
| In 25% of the cases | 20.7% | 18.9% |
| In 50% of the cases | 22.5% | 21.5% |
| Il 75% of the cases | 18.5% | 18.4% |
| Always | 36.5% | 35.4% |
| How do you manage obesity in a patient who arrived at your clinic for diseases other than obesity? | ||
| I manage it personally | 29.1% | 30.4% |
| I manage it in the context of a dedicated team | 13.5% | 15.1% |
| I refer the patient to a dietician/nutritionist in the center where I work | 29.7% | 26.9% |
| I refer the patient to a dietician/nutritionist in another center | 15.0% | 13.7% |
| I refer the patient to a 2level center for obesity therapynd | 6.6% | 6.8% |
| I invite the General Practitioner to deal with the problem | 1.4% | 0.9% |
| Other | 4.7% | 2.4% |
| Who refers patients with obesity to you? * | ||
| General Practitioners | 54.1% | 52.1% |
| Other specialists | 31.0% | 31.6% |
| Direct access | 41.5% | 39.2% |
| Nobody refers to me this kind of patients | 16.9% | 13.4% |
| When do you think it is useful to prescribe a ketogenic diet? | ||
| Never | 15.2% | 12.0% |
| Always | 5.0% | 4.7% |
| As a first approach after the failure of lifestyle intervention | 41.8% | 39.2% |
| In case of failure of pharmacological treatment | 15.8% | 9.7% |
| As bridge therapy before bariatric surgery | 22.3% | 28.5% |
| What is the usefulness of substitute foods? * | ||
| None | 10.0% | 6.6% |
| Complementary | 19.7% | 24.5% |
| The cost limits their use | 35.8% | 33.7% |
| It depends on the individual patient | 37.7% | 31.6% |
| I do not know | 12.1% | 10.1% |
| What type of exercise do you recommend to your patient with obesity? * | ||
| Anaerobic exercises | 3.8% | 4.2% |
| Aerobic exercises | 45.9% | 37.0% |
| Strength exercises | 1.8% | 3.5% |
| Flexibility exercises | 1.5% | 0.7% |
| Individualized exercises in relation to the type of patient | 47.7% | 43.6% |
| The duration and intensity of the exercise are important, not the type | 11.3% | 7.1% |
| Mixed program that includes all types of exercise | 17.7% | 21.7% |
| Exercise rarely solves the problem | 2.9% | 3.3% |
| Who do you think should be recommended psychological support in the management of obesity? | ||
| Everyone | 41.9% | 38.0% |
| Over half of the cases | 32.2% | 30.2% |
| 25-50% of the cases | 16% | 14.2% |
| < 25% of the cases | 6.9% | 5.7% |
| Only in the presence of psychiatric problems | 3.0% | 2.1% |
Pharmacological treatment of obesity
Table 3 summarizes attitudes and practices relative to the treatment of obesity.
In the 2024 survey, the first approach to treating patients with BMI between 30 and 34 kg/m2 was pharmacological treatment (associated with lifestyle interventions) for 75.7% of participants, as compared to 65.2% in the previous survey. Also, for patients with BMI between 35 and 39 kg/m2 the proportion of respondents preferring pharmacological treatment as the first option increased from 38.5% in 2022 to 49.8% in 2024. In patient with severe obesity (BMI ≥40 kg/m2), surgery or referral to a specialized center remained the commonest approaches. However, even in this case the choice of pharmacological treatment as initial approach rose from 12.6% to 20.0%.
Regarding the type of pharmacological treatment, the reported use of metformin, orlistat, and naltrexone/bupropion remained unchanged. However, there was a significant increase in the use of liraglutide. Specifically, its average usage rose from 10% in 2022 to 25% in 2024. Moreover, the upper quartile reached 50%, indicating that one-fourth of participants prescribed liraglutide to at least half of their patients with obesity. The perception of the obstacles to the prescription of drug therapy for obesity also changed; in fact, the proportion of respondents reporting side effects, resistance on the part of the patient, poor effectiveness or lack of durability decreased, while the percentage of those considering cost of treatment as the major barrier increased from 71.9% to 80.0%. Expectations for successfully managing obesity in over 50% of patients through a combination of lifestyle interventions and drug therapy increased from 20.1% to 27.4%. Additionally, the percentage of endocrinologists aware of upcoming obesity treatments significantly rose from 40.5% in 2022 to 77.8% in 2024. Expectations for enhanced effectiveness with new medications also rose from 36.6% to 50.0%.
| Item | 2022 survey | 2024 survey |
|---|---|---|
| What is your first approach to treating patients with BMI between 30 and 34 kg/m?2 | ||
| Pharmacological | 65.2% | 75.7% |
| Surgical (only with comorbidities) | 9.8% | 4.7% |
| Referral to a 2level centernd | – | 1.2% |
| What is your first approach to treating patients with BMI between 35 and 39 kg/m?2 | ||
| Pharmacological | 38.5% | 49.8% |
| Surgical | 18.0% | 3.8% |
| Surgical (only with comorbidities) | 5.1% | 11.3% |
| Referral to a 2level centernd | 32.6% | 26.7% |
| What is your first approach to treating patients with BMI ≥40 kg/m?2 | ||
| Pharmacological | 12.6% | 20.0% |
| Surgical | 16.5% | 24.8% |
| Surgical (only with comorbidities) | 26.1% | 11.1% |
| Referral to a 2level centernd | 43.3% | 37.5% |
| In what percentage of patients do you use: | ||
| Metformin | 30 [10-50] | 30 [10-50] |
| Orlistat | 0 [0-10] | 0 [0-5] |
| Naltrexone/Bupropion | 0 [0-5] | 0 [0-5] |
| Liraglutide | 10 [0-30] | 25 [5-50] |
| What is the major obstacle to prescribing drug therapy for obesity? | ||
| Side effects | 34.6% | 20.0% |
| Cost | 71.9% | 80.0% |
| Resistance on the part of the patient | 21.9% | 14.2% |
| Poor effectiveness | 14.5% | 4.7% |
| Limited durability | 25.6% | 20.3% |
| Distrust on the prescriber | 6.5% | 4.5% |
| What factors negatively affect adherence and therefore the persistence of the results of drug therapy?* | ||
| Side effects | 44.9% | 35.6% |
| Cost | 64.9% | 72.4% |
| Insufficient motivation | 55.3% | 38.9% |
| Therapeutic failure | 38.1% | 26.7% |
| Distrust of the prescriber | 6.5% | 5.4% |
| In what percentage of cases do you think obesity can be successfully managed in the long term with lifestyle intervention combined with drug therapy? | ||
| <10% | 13.4% | 8.8% |
| 10-30% | 38.0% | 27.8% |
| 31-50% | 28.5% | 27.1% |
| >50% | 20.1% | 27.4% |
| Are you aware of new drugs coming for obesity therapy? | ||
| Yes | 40.5% | 77.8% |
| Do you think the availability of new drugs: | ||
| Will increase the number of patients candidate to drug therapy | 56.1% | 55.2% |
| Will improve the effectiveness of drug therapy | 36.6% | 50.0% |
| Will improve the durability of drug therapy | 30.4% | 28.1% |
| Will reduce the costs of treatment | 12.6% | 13.9% |
| Will not lead to substantial changes | 7.6% | 5.2% |
Discussion
The findings of this extensive survey highlight the significant impact of obesity on the clinical practice of Italian endocrinologists. Over 40% of respondents indicated that one in three to over half of patients attending their wards have obesity, with an increasing trend in comparison with the previous survey. However, one in five endocrinologists still address obesity in only 25% or fewer of the patients seeking care for other endocrinological conditions.
Our survey documented changes in endocrinologists' attitudes and practices regarding the treatment of obesity. In particular, the proportion of participants considering pharmacological treatment as the initial approach to patients with obesity increased, while fewer prioritized surgery or referral to specialized centers as the primary strategy. This suggests that the availability of safe and effective anti-obesity drugs, along with the educational activities promoted by AME, may have encouraged endocrinologists to more frequently consider pharmacological treatment as an initial approach, along with lifestyle interventions.
The percentage of endocrinologists referring patients to specialized centers increased with BMI. However, even in cases of severe obesity, only one-third of participants considered bariatric surgery as the primary treatment option. These findings emphasize the need for a structured, multidisciplinary approach to obesity management, integrating shared diagnostic and therapeutic pathways for comprehensive patient care.
The survey underscores the significant underutilization of anti-obesity medications in routine clinical practice, despite a promising increase in liraglutide use compared to the previous survey. These findings reflect the increasing body of evidence supporting the beneficial effects of GLP1 receptor agonists not only for weight reduction, but also for cardio-renal protection (25).
The overall picture emerging from this survey, conducted two years apart from the previous one, suggests a greater awareness of endocrinologists about the potential of treating patients with obesity with GLP1 receptor agonists, with less worries about side effects and patient resistance. Of note, poor effectiveness almost disappeared among the reported obstacles to prescribing anti-obesity drugs. The different distribution of responders, characterized by greater field experience, may have at least partially influenced the higher prescribing attitude toward liraglutide observed in the survey. However, the percentage increase in liraglutide prescribers in this survey is much greater than the increase in participants with long-standing experience. Also, compared with the previous survey, the proportion of participants aware of upcoming new anti-obesity medications increased substantially from 40.5% to 77.8%, suggesting a growing interest of endocrinologists for the management of obesity. Furthermore, respondents manifested greater expectations regarding the possibility of achieving long-term success through a combination of lifestyle interventions and new drug therapies.
However, these changes in attitudes only partially translated into changes in behavior. In fact, compared to the previous survey, there was no clear increase in the tendency to take responsibility for the management of people with obesity, and the use of medications remained limited. It is plausible that translating knowledge into practice requires more time and more intensive educational interventions. Furthermore, perceived barriers to drug prescription still persist. In this respect, the cost of treatment can limit a wider use of new anti-obesity drugs and was identified as a major obstacle by 80.0% of participants, significantly affecting adherence to long-term therapy. Notably, the lack of reimbursement by the Italian National Health System further complicates access to sustained treatment, presenting a significant challenge for patients. Other commonly cited barriers to drug therapy included concerns about side effects and the limited durability or effectiveness of treatment. The perception that existing weight-loss medications may not be safe or effective aligns with previous findings (17, 26) and may partly explain the low prescription rates. However, comparison with the previous survey suggests that confidence in new treatments is increasing. Additionally, 14% of participants identified patient resistance as an obstacle to prescribing anti-obesity drugs, while 38.9% of the respondents cited insufficient patient motivation as a key reason for poor adherence and long-term treatment outcomes. Several factors may contribute to patients' reluctance to pursue pharmacological treatment, including high costs, side effects, and perceived limited efficacy. Moreover, a lack of recognition of obesity as a chronic condition, difficulties in viewing weight-loss treatment as a long-term commitment, social and environmental challenges that hinder weight loss, and the presence of multiple comorbidities can all contribute to patient resistance (27). Therefore, endocrinologists should be trained to recognize treatment barriers early to improve the likelihood of long-term success.
Our study has some limitations. First, the response rate was 16.6%, which may reflect limited awareness about obesity management. However, previous surveys have reported response rates ranging from 10.8% to 34% (19, 28 –31). Additionally, the survey sample may not fully represent the broader community of endocrinologists. However, the respondents' sex, age, regional distribution, and professional experience were consistent with the overall demographics of AME members. Two new and very effective anti-obesity drugs, semaglutide and tirzepatide, are presently marketed in Italy but were not available when the survey was conducted. Lastly, participants in the survey may have been those with a greater interest in obesity management, potentially leading to an optimistic picture of obesity-related attitudes and practices among Italian endocrinologists.
In conclusion, our survey highlights that while endocrinologists frequently encounter patients with obesity, they often do not actively address or manage the condition. Since individuals with obesity may not recognize the need for weight reduction until it affects their health, it is crucial for endocrinologists to initiate conversations about weight early on to facilitate timely interventions and prevent obesity-related complications.
Although currently available anti-obesity medications are safe and effective, with even more promising treatments on the horizon, pharmacological therapy remains underutilized. However, there are indications of a growing adoption of new therapies in clinical practice. In this respect, a dedicated educational program should strengthen endocrinologists' familiarity with new drugs and promote better recognition of bariatric surgery indications. Addressing the unmet educational needs of endocrinologists is essential to enhance their awareness of obesity and increase their confidence in managing this widespread condition, which has a profound impact on society.