Obesity has reached epidemic proportions in the United States. With more than half of all adult Americans categorized as either overweight or obese (5), there is a growing need for interventions designed to treat and manage these conditions. Therefore, finding a solution is of critical importance to the health of the United States. The condition remains underdiagnosed and undertreated by physicians in the U.S. health care system (8). Physiological risk factors such as high blood pressure, diabetes, cardiovascular disease, stroke, arthritis, and gall bladder disease increase in relation to an increase in weight, as does the propensity for psychological disorders (12). Calls for the increased treatment of obesity have existed globally for years and have only increased as the prevalence of the condition has increased (4,7).
In a recent study of the Behavioral Risk Factor Surveillance System, only 42% of individuals who were obese, from a sample of nearly 13,000, reported that their doctor had advised them to lose weight (6). Almost 80% of respondents to a nationwide survey, two-thirds of whom were overweight or obese, reported that their weight was not a health concern (13). In fact, treatments for obesity are considered “lifestyle drugs” (4). The term “lifestyle medication” has had several definitions over the years but reflects therapy that is patient-selected (9). Because of this, treatments for obesity are grouped with those for baldness, suggesting a potential gap in the importance of treatments for obesity.
The treatment of obesity is not simple. Pharmacological and behavioral interventions for obesity have had limited success and have generated little satisfaction among physicians (8). Currently available prescription weight loss medications include Xenical, Adipex-P®, Fastin® (phentermine), Bontril® SR (phendimetrazine), and Meridia® (sibutramine). Phentermine, phendimetrazine, and sibutramine are derivates or chemical relatives of amphetamine and work to suppress a patient's appetite (2). Xenical works to block the absorption of fat in the digestive system and thus prevent those fats from being stored by the body (3). In general, over-the-counter (OTC) weight loss aids are not regulated by the Food and Drug Administration for accuracy of claims (10). The deaths that resulted from the primary ingredient in Metabolife®, ephedrine, are a perfect example of the need for monitoring of patients consuming OTC remedies (10). Comprehensive reviews of OTC and prescription treatments are available from several sources (10,14).
Certified personal fitness trainers (CPT) are important partners in health care and are key players in the battle against obesity. Often overlooked, CPTs usually have a wealth of knowledge in the areas of physical fitness and weight management. Many organizations offer fitness professionals certifications to train the general public. Initially, this research examined the current state of certification criteria among organizations that certify personal trainers. Information about the certification examinations for multiple agencies was retrieved from associated websites and reviewed for questions or components related to antiobesity medications. All organizations required knowledge in the areas of nutrition, fitness, anatomy, and physiology; none included a testing component concerning pharmacotherapy for the purpose of weight loss. The organizations listed in Table 1 reflect approximately 10% of the 125 certification organizations found in an Internet search.
This lack of a drug education requirement highlights a key issue facing the increasing involvement of both pharmacotherapy and CPTs in the fight against obesity. As a common and trusted touchpoint for patients working to lose weight, CPTs have the ability to support patients engaging in diet, exercise, and pharmacotherapies to reduce weight. However, with a lack of focus on pharmacotherapy in the certification process and with thousands of CPTs in America, it is important to understand CPTs' views and knowledge of pharmacotherapy for weight loss. The purpose of this research was to develop a baseline understanding of CPTs' knowledge and perceptions of both prescription and nonprescription weight loss drugs. Because patients often discuss potential alternative diets and treatments with their CPTs and because, of all information sources, CPTs are seen more frequently than other providers, CPTs may have an increased potential to identify potentially life-threatening issues as OTC and prescription therapies increase in availability.
Experimental Approach to the Problem
Given the lack of a baseline understanding of CPT knowledge and perceptions of pharmaceutical weight loss products, the design of this study was purely exploratory in nature. Multiple items were developed to assess CPT-held beliefs about weight loss medications relative to other interventions. These items were pretested and revised into a 16-item scale. This was used to interview 45 CPTs. These trainers were recruited using a regional breakdown of fitness centers listed in the telephone directories. Criteria for inclusion were dependent on having knowledge about prescription weight loss medications.
Of the 45 trainers interviewed, 15 were located in the southern part of the United States, 15 in the East, 11 in the West, 3 in the Midwest, and 1 in Canada. Two trainers were not included in the study because of incomplete interviews. A total of 43 interviews were used in the final analysis. All trainers held current National Federation of Professional Trainers (NFPT) or American College of Sports Medicine (ACSM) certifications to practice personal training. The NFPT and ACSM have offered personal training education and professional certifications for many years and represent roughly 35,000 professional members (1,11).
The average age of the trainers in the study was 38 years. The sample consisted of 19 women (44%) and 26 men (56%). On average, the CPTs in the study had spent 7 years as personal trainers. The average number of clients was 16, with 46% of those clients reported to be overweight or obese. On average, the gyms at which the trainers worked had 601 members, with 27% of those members reported to be overweight or obese. Fifteen trainers worked at facilities that reported having more than 500 active members.
Interviews were conducted via telephone to assess the trainers' current level of knowledge and perceptions of weight loss drugs. A 7-item Likert-type scale was used to assess perceptions of weight loss medications. Questions about both prescription and OTC medications were included in the survey instrument. The survey was developed by experts in the pharmaceutical, health promotion, and exercise science fields. Once developed, the survey was pretested by five local CPTs who held either a NFPT or an ACSM certification.
The current recommendations by the CPTs in this study were assessed by the questions in Table 2. There was a low rate of referral for advice about and medication for weight loss among the CPTs in the study.
CPT knowledge and unaided recall of the names of medications for weight loss were limited. Almost half of the sample had no knowledge of weight loss medications. Of the 43 trainers surveyed, 58% were able to list one currently or previously available medication, 42% were able to list two medications, and no CPTs were able to name more than two medications.
Perceptions of Weight Loss Medications
In examining the perceptions of the use of weight loss medications, a battery of items was used to evaluate perceptions of obesity, obesity medications, and the role of traditional program measures of diet and exercise relative to pharmacological interventions. First, the general impression of both OTC and prescription weight loss medications was assessed on a scale of 1-7 (1 = very negative, 7 = very positive). The average responses of the 24 trainers with medication knowledge/awareness show that those who reported having knowledge about prescription medications and OTC medications had negative perceptions (mean responses of 2.33 and 1.58, respectively).
The use of pharmacological interventions for weight loss was perceived very negatively by the trainers in this study. The role of medications as a component of a weight loss program was assessed. In addition, the perceptions of traditional and nontraditional weight control measures were assessed. All assessments were queried on a 1-7 scale (1 = strongly disagree, 7 = strongly agree). The mean responses are presented in Table 3.
Trainers did not believe that assessing the need for weight loss pharmacotherapy was important (mean 2.42) or that antiobesity medication use was an important component of a weight loss program (mean 1.96). CPTs also had the perception that people overestimate the value of prescription medications relative to exercise, diet, and lifestyle changes (mean 6.08). An interesting finding was that most CPTs held the perception that other trainers would recommend that their clients not take prescription medications (mean 3.5) and that other trainers would try to illustrate that prescription medications are less of a solution to weight loss than diet and exercise (mean 5.54). Despite these overall negative perceptions, the mean response to wanting to know more about prescription weight loss medication was considerably high (mean 5.71).
The negative perceptions of weight loss products among CPTs continued to be negative and seemed to pertain to both prescription and OTC agents. Items such as “Clients that use prescription medications are more likely to maintain a diet and exercise regimen over time” and “Some clients could not succeed in weight loss without OTC medications” had among the lowest agreement scores (mean 2.0 and 1.75, respectively). It was apparent that CPTs believe that the potential for drug interactions is an issue for concern (mean 6.67).
It is evident that the CPTs interviewed had preconceived notions about medical interventions for weight loss and that those notions were not as positive as trainers' notions about other interventions available, such as diet and exercise. In addition, there was a fairly consistent lack of awareness of the available weight loss products and the implications of those products for clients.
Several issues arise from the results of this study and lead to the generation of research questions. First, in situations in which patients/clients are receiving care from both a physician and a CPT, how does message congruence affect compliance with the medical and personal training regimens? Second, is education of CPTs concerning the benefits, efficacy, and side effects of prescription and OTC weight loss medications necessary and useful? Third, if this bias against the use of medications in weight loss programs is confirmed, what is the role of that bias in the development of programs and the provision of support to CPT clients?
In this research study, we have identified the need for further studies of fitness professionals and antiobesity medications as a form of weight loss intervention. Although there is no evidence of any pharmacotherapy testing component in organizations that certify personal trainers, it is not the intent of this study to fault or criticize these organizations for not having such components. It is clear that those who wish to become a CPT must have well-rounded knowledge in anatomy, exercise behavior, exercise science, exercise physiology, exercise testing and prescription, and nutrition, as well as countless other psychology-, health-, and science-related components.
In this study, we evaluated responses from trainers who held a current NFPT certification or certification from the ACSM to practice personal training in either the public or private sector. As such, this work is limited in that it does not include trainers who hold other certification, such as the National Strength and Conditioning Association or Certified Strength and Conditioning Specialists from the National Strength and Conditioning Association. Thus, the results of this exploratory research cannot be generalized until further research is undertaken in additional samples. Also, the study design did not include responses from those trainers who did not report having knowledge of prescription weight loss medications.
The findings of this study show that CPTs have interest in antiobesity pharmacotherapy knowledge and that the current lack of knowledge may lead CPTs away from discussions of such therapies. There is an obvious need for more knowledge-based education in both nutrition and weight loss treatments. This is important as efforts increase to combat the epidemic of obesity in the U.S. Although some therapeutic interventions may be beyond the scope of a typical CPT, especially those without a baccalaureate-level degree, there potentially is an opportunity to develop educational programs to allow personal trainers to specialize in pharmacotherapy or other key issues and expand on current understanding, which is limited.
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