SDENTJ 203 5 May 2015 The Saudi Dental Journal (2015) xxx, xxx–xxx No. of Pages 5 1 King Saud University The Saudi Dental Journal www.ksu.edu.sa www.sciencedirect.com 2 ORIGINAL ARTICLE 5 Knowledge, perceptions, and attitudes of dental students towards obesity 6 K.H. Awan 4 7 8 9 10 a b c a,* , S. Khan b, Z. Abadeen c, T. Khalid b Department of Oral Medicine & Diagnostic Sciences, College of Dentistry, King Saud University, Riyadh, Saudi Arabia Department of Restorative Dentistry, Faculty of Dentistry, University of Malaya, Kuala Lumpur, Malaysia Department of Restorative Dentistry, Faculty of Dentistry, Riphah International University, Islamabad, Pakistan Received 13 October 2014; revised 23 November 2014; accepted 26 January 2015 11 13 14 KEYWORDS 15 Obesity; Dental students; Knowledge; Questionnaire study 16 17 18 19 Abstract Aims: Obesity is a chronic medical condition associated with various oral health problems. The aim of this study was to assess the knowledge, perceptions, and attitudes of dental students towards obesity. Material and methods: Second-, third-, and fourth-year dental students completed a self-administered questionnaire. An ethics committee approved the study. Participants were asked questions focused on three areas: (i) knowledge, (ii) perceptions, and (iii) attitudes about obesity. Data analyses were carried out using SPSS version 20. Results: Among the dental students, 78.9% received 0–1 h of formal education about obesity. The mean score of the total time allocated for obesity-related education was 1.31 ± 0.23 h. Eighty-nine percent of the dental students agreed that obesity is a chronic medical condition, 46.2% agreed that they would modify their equipment and office furniture to accommodate obese patients, and 46.8% were interested in learning more about obesity in dental school. Conclusion: Obesity-related education should be implemented as a formal component of dental student training. Oral health practitioners should also provide their patients with information about how weight loss is beneficial to both general and oral health. ª 2015 Production and hosting by Elsevier B.V. on behalf of King Saud University. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). * Corresponding author at: Department of Oral Medicine & Diagnostic Sciences, College of Dentistry, King Saud University, P.O. Box 60169, Riyadh 11545, Saudi Arabia. Tel.: +966 1 467 7422; fax: +966 1 467 9018. E-mail address: kamranhabibawan@gmail.com (K.H. Awan). Peer review under responsibility of King Saud University. Production and hosting by Elsevier 1. Introduction 20 Obesity is a global health problem that is spreading at an alarming rate across the world, particularly in the Asia– Pacific Region. The worldwide prevalence of obesity is 27.8% (WHO, 2008). According to the Global Burden of Disease Study, Pakistan is ranked as the ninth most obese population in the world (Ng et al., 2014). Since obesity has a high prevalence worldwide, it is considered and prioritized as a major issue with regard to the economics of developed nations (Cecchini et al., 2010). 21 http://dx.doi.org/10.1016/j.sdentj.2015.01.005 1013-9052 ª 2015 Production and hosting by Elsevier B.V. on behalf of King Saud University. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Please cite this article in press as: Awan, K.H. et al., Knowledge, perceptions, and attitudes of dental students towards obesity. The Saudi Dental Journal (2015), http://dx.doi.org/10.1016/j.sdentj.2015.01.005 22 23 24 25 26 27 28 29 SDENTJ 203 5 May 2015 No. of Pages 5 2 78 Obesity is a disease with multiple aetiological factors, with genetics and specific obesity-related genes playing key roles (Stunkard et al., 1986). However, there are also some environmental links to obesity (von Deneen et al., 2011). Due to the recent trends associated with urbanization, including increased refined food product consumption, unhealthy dietary habits, and a lack of physical activity, obesity is spreading fast (Lamb et al., 2010). Obesity has been identified as a risk factor for various systemic diseases, including hypertension, cardiovascular disease, metabolic diseases, osteoarthritis, respiratory difficulties, and some oral diseases, such as periodontal disease (Eckel et al., 2005; Haslam and James, 2005; Stumvoll et al., 2005; Wilson et al., 2002). In addition, obesity is associated with an increasing burden of oral diseases and adverse effects on oral health-related quality of life (Ritchie and Connell, 2007; Saito et al., 2005, 2001). As a result, medical and dental professionals are facing challenges associated with identifying patients with obesity and prioritizing their general and oral health care needs (Basdevant and Ziegler, 2002). Health care professionals are responsible for preventing and identifying weight issues and for providing advice to the patients (Basdevant and Ziegler, 2002; Jackson et al., 2013). Studies focused on patient beliefs have reported that health professionals are the primary group capable of helping patients identify obesity and its associated health risks (Bocquier et al., 2012). However, physicians were found to be hesitant to carry out obesity prevention and management counselling to their patients (Kristeller and Hoerr, 1997). The reasons for this are unknown, but may be due to a lack of knowledge and negative attitudes of health care professionals towards obesity management (Foster et al., 2012; Harvey and Hill, 2001a,b; Hebl et al., 2003). As obesity is one of the major predisposing factors for oral diseases, there is a need to counsel patients visiting dental hospitals and clinics in order to identify the underlying causes of obesity and carry out obesity management and prevention procedures. There is a lack of data about the understanding of dental professionals with regard to obesity management (Ritchie and Connell, 2007). Studies have reported that more than one-third of dental students and dental hygiene students had one hour or less of obesity education as part of their dental school curriculum (Magliocca et al., 2005). These findings suggest that there is an urgent need for additional training about obesity-related health risks as part of the dental school curriculum. Therefore, the purpose of this study was to understand and identify the underlying reasons for why dental professionals are often neglectful, reluctant, and hesitant when treating obese patients, and to determine the current state of knowledge, perceptions, and attitudes of dental students with regard to obesity and its management. 79 2. Material and methods 80 2.1. Study population and design 81 This was an anonymous, cross-sectional study conducted among second-, third-, and fourth-year dental students of the Faculty of Dentistry, Riphah International University, Islamabad, Pakistan, over a three-month period from January through March 2014. Students were given the self-administered questionnaire along with detailed instructions for completing the questionnaire individually. The questionnaires 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 82 83 84 85 86 87 K.H. Awan et al. were distributed to the students during breaks from lectures or work. The students were required to complete the questionnaires on site and to return them immediately to the research team. Approval of the study was obtained from institutional research and ethics committees. Social demographic factors of age (mean ± SD), sex, year of education, and geographic locations were assessed. 88 2.2. Instrument and data collection 95 Our study used a modified version of the self-administered questionnaire developed by Foster et al. (2003) to assess the knowledge, perceptions, and attitudes of dental students towards obesity. The questionnaire was peer-reviewed, piloted, and determined to be comprehensive. The questionnaire consisted of 16 items, with three sections: (i) knowledge, (ii) perceptions, and (iii) attitudes. Participant responses were based on the Likert scale, which included five responses ranging from strongly agree to strongly disagree. All participants completed the questionnaire during a single meeting using indelible pencil. Knowledge-based questions were focused on the total number of credit hours allocated to obesity education in dental school and the ability of the participant to define, diagnose, and understand obesity as a health problem. Perception-based questions were focused on the ability of participants to describe their motivation towards making accommodations for obese individuals in the dental setting and towards assessing patient dietary habits. Attitude-based questions were focused primarily on the behaviour and feelings of the dental students towards obese patients. Negative responses graded under strongly disagree and disagree were categorized as disagree, whereas positive responses graded under strongly agree and agree were categorized as agree. The neutral response was input with the mean value of response for each question. 96 89 90 91 92 93 94 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 2.3. Data analysis 120 Data were analysed using Statistical Package for the Social Sciences (Released 2009. PASW Statistics for Windows, Version 18.0. Chicago: SPSS Inc.). The frequency distribution was used to analyse each participant’s characteristics and the number of hours allocated for obesity-related education among dental students. Participant responses were assessed based on the frequency and percentage of participants who agreed or disagreed with the questions. 121 3. Results 129 A total of 218 dental students participated in this study. The response rate of participants was 99.09%. Among the participants, 63.3% were female and 36.7% were male, with a mean age of 24.0 ± 1.3 years. Table 1 shows the distribution of demographic characteristics of the participants. Seventy-nine percent of the participants reported having 0–1 h of obesity-related education as part of their dental curriculum. However, the mean score of the total time allocated for obesity-related education was 1.3 ± 0.2 h. Fig. 1 summarizes the total number of hours allocated for obesity-related education, as perceived by the dental students. The responses of participants to knowledge-, attitude-, and perception-based questions are shown in Table 2. When participants were asked whether they had attended any prior courses that helped increase their professional acumen in relation to obesity, 70.6% participants responded positively. While the majority 130 131 Please cite this article in press as: Awan, K.H. et al., Knowledge, perceptions, and attitudes of dental students towards obesity. The Saudi Dental Journal (2015), http://dx.doi.org/10.1016/j.sdentj.2015.01.005 122 123 124 125 126 127 128 132 133 134 135 136 137 138 139 140 141 142 143 SDENTJ 203 5 May 2015 No. of Pages 5 Attitudes of dental students towards obesity Table 1 Socio-demographic participants. characteristics 3 of the Characteristic (N = 218) % Age 621 22–23 P24 31 103 84 14.2 47.2 38.5 Gender Male Female 80 138 36.7 63.3 Year of study 2nd year 3rd year 4th year 66 80 72 30.3 36.7 33.0 164 of participants (89%) reported that obesity is a chronic medical disease, only 12.8% thought that small weight loss could have beneficial effects. More than half of the participants (59.6%) perceived obesity as a serious medical condition, but only a small proportion was able to define obesity (22%) or provide a differential diagnosis for obesity (35.8%). Knowledge-based questions and their responses are provided in Table 2. Participants responded about their professional impressions of obesity in sequenced questions. Around 30% of participants agreed that they would make special accommodations in their dental offices for obese patients with their equipment and office furniture. Although the majority of participants reported that the assessment of the dietary habits of their patients is important, only 47% of participants stated their interest in obesity-related courses in dental school. When asked questions about their attitudes towards obese patients, more than half of the participants reported that they feel uncomfortable examining obese patients and asking them about their dietary habits and history of appetite suppressants. Around 63% of participants thought that obese individuals are lazier than normal weight patients, and 35% of participants thought that obese patients lack will power and motivation for health. 165 4. Discussion 166 The principle objective of this study was to evaluate the knowledge, perceptions, and attitudes of dental students about obesity. The results of this study provide insights into the lack of curriculum and its overall impact on obesity-related attitudes among dental students. More than two-thirds of the dental 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 163 167 168 169 170 Figure 1 Total number of hours allocated for obesity as perceived by the dental students. students reported having between 0 and 1 h of formal obesity-related education as part of their dental school curriculum. Other studies have also identified a similar lack of dedicated obesity-related education in the dental school curriculum (Fogelman et al., 2002; Magliocca et al., 2005). One study reported that 40% of dental students had 0–1 h of formal obesity-focused education as part of their dental school curriculum (Magliocca et al., 2005). Another study reported that 72% of primary care physicians believed that they lack proper training for providing obesity-related education to their patients (Fogelman et al., 2002). These findings are disappointing and may be a result of a lack of interest and priority-setting by institutions and health authorities with regard to obesity-related education. Since Pakistan is ranked as the ninth most obese country worldwide (Ng et al., 2014), both dental and medical school curriculums should be revitalized to include courses providing obesity education. Table 2 Details of the responses given by the participants. Reponses Knowledge score a. I have taken other courses prior to dental school that educated me about obesity b. Obesity is a chronic medical disease c. Small weight losses (5–10% of body weight) can produce important medical benefits for obese patients d. Obesity is associated with serious medical conditions e. I can correctly identify the WHO definitions of overweight, obese, and morbidly obese patients Perception score a. Treating obese patients in dentistry means I will need to make accommodations in equipment and office furniture b. In my discipline, it is important to assess a patient’s dietary habits c. I would be interested in learning about obesity in dental school Attitude Score a. I have negative reactions towards the appearance of obese patients b. It is difficult for me to feel empathy for an obese patient c. I feel uncomfortable when examining an obese patient d. Overweight people tend to be lazier than the normal weight people e. Overweight people lack will power and lack motivation in comparison to normal weight people f. I would feel uncomfortable asking an obese patient about his or her dietary habits g. I would feel uncomfortable asking an obese patient about his or her past use of appetite suppressants or current and past anti-obesity medications Agree Disagree N % 154 70.6 64 29.4 194 28 89.0 12.8 24 190 11.0 87.2 130 59.6 88 40.4 48 22.0 170 78.0 64 29.4 154 70.6 170 78.0 48 22.0 102 46.8 116 53.2 144 66.1 74 33.9 110 50.5 108 49.5 130 59.6 88 40.4 138 63.3 80 36.7 76 34.9 142 65.1 100 45.9 118 54.1 108 49.5 110 50.5 N % Please cite this article in press as: Awan, K.H. et al., Knowledge, perceptions, and attitudes of dental students towards obesity. The Saudi Dental Journal (2015), http://dx.doi.org/10.1016/j.sdentj.2015.01.005 171 172 173 174 175 176 177 178 179 180 181 182 183 184 185 186 187 SDENTJ 203 5 May 2015 No. of Pages 5 4 188 189 190 191 192 193 194 195 196 197 198 199 200 201 202 203 204 205 206 207 208 209 210 211 212 213 214 215 216 217 218 219 220 221 222 223 224 225 226 227 228 229 230 231 232 233 234 235 236 237 238 239 240 241 242 243 244 245 246 247 248 The majority of the participants in our study were unable to define obesity. In addition, most of the participants failed to identify obesity and to recognize potential health benefits associated with weight loss. Similar findings were observed in previous studies of dental students who had a limited understanding of obesity (Magliocca et al., 2005). This lack of knowledge in identifying obesity and its related health risks poses a significant challenge to dental professionals and raises serious questions about their clinical training. Encouragingly, more than 70% of the participants recognized obesity as a chronic medical condition. This finding was consistent with other studies, where 92% of primary care physicians and 56.3% of dental students were reported to recognize obesity as a chronic medical condition (Foster et al., 2003; Kumar et al., 2012). In our study, only around 30% of participants reported feeling a need to make special accommodations with their dental office equipment and furniture for obese individuals. A similar finding was reported by Kumar et al. (2012), where 54.4% of the dental students responded negatively towards making special accommodations for obese patients in their dental offices. This may be due to a fear that the prerequisite to make special accommodations for obese patients may affect the cost-effectiveness and feasibility of their dental set-up. The majority of the participants in our study believed in the importance of dietary assessments for their patients. This finding is very important, as it may help establish obesity-related risk factor assessments and facilitate the implementation of prevention protocols, such as dietary modifications, increased physical activity, and exercise programs. Notably, almost half of the participants in our study were in favour of having more obesity-related courses during their dental school training. These findings were consistent with Kumar et al. (2012), where 60.6% of dental students were interested in learning more about obesity. This suggests that dental students are motivated to learn about obesity, and that the proper implementation of a curriculum focused on obesity prevention and rehabilitation may play a key role in controlling obesity. Our assessment of the attitudes of dental students towards obesity yielded some worrisome findings. It revealed that dental students considered obesity to be related to personality and aesthetics. It showed that the dental students attributed personality characteristics, such as appearance, laziness, feeling uncomfortable, lack of self-control, and low motivation, to obesity. Around 64% of the dental students considered obese people to be lazier than normal weight people. Over 50% of the dental students reported that they feel uncomfortable asking obese patients about their dietary habits and diet control medications. Similarly, more than half of the participants reported a negative reaction to the appearance of obese patients and were uncomfortable with examining obese patients. Several other studies have reported similar obesity-related attitudes among health care providers (Blumberg and Mellis, 1985; Cecchini et al., 2010; Harvey and Hill, 2001a,b; Lamb et al., 2010; Lois and Kumar, 2009; Maroney and Golub, 1992; Najman et al., 1982). On the contrary, our findings were inconsistent with those of a study by NeumarkSztainer et al. (1999), conducted among health care providers, where the majority of respondents did not associate obesity with personality characteristics. K.H. Awan et al. 5. Conclusion 249 Dental education reforms lack the basic and specialized concepts of obesity-related education as a core component of the dental curriculum. Since obesity is a potential modifying factor for a variety of dental conditions, it should be an integral part of the dental curriculum, with a focus on the need for implementing proper obesity-related education in response to dental treatment needs. Oral health physicians should also educate their patients about the benefits of weight loss with regard to both their general and oral health. 250 Conflict of interest 259 The authors have no conflicts of interest to declare. 260 References 261 Basdevant, A.L.M., Ziegler, O., 2002. Recommendations for the diagnosis, the prevention and the treatment of obesity. Diabetes Metab. 28 (2), 146–150. Blumberg, P., Mellis, L.P., 1985. 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