Huang, Jian MD; Yu, Herbert MD, PhD; Marin, Estela MA; Brock, Stephanie MA; Carden, Donna MD; Davis, Terry PhD
The prevalence of obesity in the United States has risen dramatically over the past two decades and continues to rise at an alarming rate.1,2 Obesity is responsible for 300,000 deaths annually and costs $61 billion in direct medical expenses annually.3 Obesity is also the second leading cause of preventable deaths in the United States and significantly increases the risk of developing type 2 diabetes mellitus, hypertension, and dyslipidemia, conditions directly related to the development of coronary artery disease.2,4 Currently, 58% of American adults are overweight [(body-mass index [(BMI)] ≥ 25)] or obese (BMI ≥ 30).2 Unless effective strategies to control obesity are implemented, the health consequences and economic burden of obesity are likely to worsen.
The dramatic increase in the prevalence of obesity is probably a consequence of modifiable behaviors, such as overconsumption of high caloric foods and sedentary lifestyles.3 If these behaviors are modified, the prevalence and complications of obesity could be reduced because even modest weight loss improves dyslipidemia as well as blood pressure and glucose control.4
The U.S. Preventive Services Task Force, the American Heart Association, and the American Diabetes Association all recommend that primary care physicians counsel patients regarding modifiable coronary artery disease risk factors, including obesity, during preventive health examinations.5–7 Primary care physicians are an important source of preventive health information,8 yet nationwide, weight loss counseling rates are inadequate.1,9,10 For example, the Centers for Disease Control and Prevention reported that of more than 750 million outpatient visits in 1999, only 13.7% of patients received counseling about diet, and 9.8% received counseling about exercise.10 Resident–physicians’ attitudes toward counseling and public hospital patients’ responses to physicians’ recommendations about weight loss are largely unknown.
Obesity disproportionately affects minorities and people with low socioeconomic status,1,2,11 many of whom receive health care in university-based public hospitals.11 To improve preventive care in public hospitals, it is important to identify physician barriers to providing weight loss counseling and to identify patients’ knowledge and attitudes about weight loss in this environment. Therefore, we sought to determine physicians’ barriers to providing weight loss counseling in a public hospital, patients’ recall of physicians’ weight loss recommendations, and the influence of physicians’ weight loss counseling on patients’ understanding, motivation, and behavior regarding weight loss.
We conducted our study in two primary care clinics with 30,000 annual outpatient visits at Louisiana State University Health Sciences Center-Shreveport (LSUHSC-S). Patients are routinely followed up in the two clinics by all internal medicine residents, who are supervised by faculty preceptors. Approximately 75% of the patients are African American, 68% are female, and 81% are overweight or obese.11
Physician Focus Groups
We held four focus groups of LSUHSC-S faculty and internal medicine residents between February and May 2001 to identify physicians’ barriers to providing weight loss counseling in our clinics. We structured the focus groups according to the guidelines recommended by Debus12 and used scripted probes to encourage participation and clarify answers. Each 75-minute focus-group session was attended by six physicians and led by one of us (TD). A total of six faculty and 18 residents participated in the four focus groups. Participants ranged in age from 27 to 52 years, 78% were male, and 93% were white. Faculty received $100 each and residents $50 each for their participation. Two research associates transcribed participants’ responses to the scripted questions. Using notes taken during each session, we identified consensus themes as those mentioned by more than one participant in each focus group and prevailing themes as those confirmed by the group participants at the end of each session. Themes were rank-ordered by how frequently they were mentioned.
Patient Exit Interview
We recruited a convenience sample of patients age 18 years or older and each with a BMI ≥ 25 for study participation from the two primary care clinics between September 2001 and January 2002. Less than 5% of patients declined to participate. The primary reason for refusal was lack of time. Patients with uncontrolled psychiatric diseases and those who spoke English as a second language were excluded from the study. A total of 210 patients participated.
A research associate asked patients to participate in our study immediately after each clinic visit. After obtaining written informed consent, research associates conducted a confidential, structured patient exit interview. The interview included questions on the patient's understanding of the relationship between weight and health, the effect of a 10% weight loss, the resident–physician's specific weight loss recommendations, the patient's motivation for weight loss, and previous and current weight loss activities. The patient's readiness for weight loss was based on Prochaska's stages of change model.13 Patients were asked to categorize themselves by selecting one of the statements that best represented their readiness for weight loss (see List 1).
We administered the Rapid Estimate of Adult Literacy in Medicine (REALM) to assess patients’ literacy.14 Because patients’ literacy levels may affect their understanding and recall of physicians’ weight loss recommendations, we included literacy scores in the logistic regression.
While research associates interviewed each patient, one of us (JH or DC) reviewed charts to determine each patient's age, gender, race, weight, height, employment status, insurance status, and clinical diagnoses. Each patient's weight and height were routinely measured with light clothing and no shoes by nursing staff and recorded on the medical chart. Clinical diagnoses, including obesity, were based on a master problem list charted by residents on the record from the latest clinic visit. BMI was calculated as body weight in kilograms divided by height in meters squared.4 The LSUHSC-S Institutional Review Board approved the study protocol in advance.
Most of the questionnaire data collected were categorical, except for age, height, and weight. We compared categorical data using chi-square test or Fisher exact test. To control for confounding variables, we performed multivariate analysis using logistic regression model (SAS software version 8.2, SAS Institute, Inc., Cary, North Carolina).
During the focus-group discussions, physicians identified several barriers to providing weight loss counseling. The identified barriers, ranked by frequency, are reported in List 2.
The demographic characteristics of the 210 patients who participated in our study are shown in Table 1. The mean BMI of the patients was 39, with a range of 26–65; 93% were obese (BMI ≥ 30), 7% were overweight (BMI = 25–29.9). Ninety-six percent of the patients had one or more obesity-related chronic diseases. Eighty-four percent had hypertension, 42% had type 2 diabetes mellitus, 45% had dyslipidemia, and 18% had cardiovascular diseases. Obesity was documented as a separate clinical diagnosis in only 14.4% of the patients with a BMI of 30 or higher.
Sixty-one percent of the patients believed their weight affected their health, 63% recognized that the numeric equivalent of a 10% weight loss would have some health benefit, 89% reported the need to lose weight, and 88% wanted to lose weight. Ninety percent of the patients reported having tried to lose weight previously. Concerning patients’ stages of readiness to lose weight, 36% were not considering or were thinking about weight loss (precontemplation or contemplation stage), 33% were preparing to lose weight (preparation stage), and 31% were currently trying to lose or maintain their weight (action or maintenance stage).
Physicians’ Weight Control Recommendations
Seventy-nine percent of the patients recalled being counseled by the physician to lose weight, yet only 28% recalled being given specific weight loss recommendations. Of these, 17% recalled being counseled on dietary modification and 5% recalled being counseled to increase physical activity. Only an additional 5% recalled being given the recommended weight loss strategies of combined diet and exercise. The remaining 1% recalled being informed of the option of pharmacologic or surgical therapy for weight loss.
Patients with a BMI of 35 or higher or with type 2 diabetes mellitus were more likely to report being counseled to lose weight than patients without type 2 diabetes mellitus (χ2 = 4.77; p < .03) or patients with a BMI of less than 35 (χ2 = 17.67; p < .001). This difference remained statistically significant after adjusting for age, gender, race, literacy level, and number of co-existing obesity-related diseases [(odds ratio [(OR)], 5.44; 95% confidence interval [(CI)], 2.01–14.71; p < .001)], where the outcome variable was patients’ recall of being counseled to lose weight and the primary independent variables were comorbidities and BMI, respectively, adjusted for age, gender, race, and literacy level.
Sixty-three percent of the patients were referred to a dietitian. Logistic regression analysis indicated that patients with type 2 diabetes mellitus, dyslipidemia, or both were more likely to be referred for dietary counseling (OR, 6.75; 95% CI, 2.77–16.43; p < .001) than were patients with obesity alone (OR, 3.04; 95% CI, 1.25–7.39; p = .014), where the outcome variable was patient referral to a dietitian and the primary independent variables were diagnosis of type 2 diabetes mellitus or dyslipidemia and BMI, respectively, adjusted for age, gender, race, and literacy level. Dietitian referral was not significantly related to other variables.
Impact of Weight Loss Recommendations on the Patient
Patients who recalled having received weight loss counseling from the physician were more likely to have a better understanding of obesity-associated health problems and benefits from weight loss, as well as a stronger desire and increased readiness for weight loss (precontemplative stage versus all other stages). These patients were also more likely to be engaged in current or previous weight loss activities (see Table 2). The associations between the physicians’ counseling and the patients’ understanding of the need to lose weight (OR, 3.69; 95% CI, 1.21–11.24; p = .02), desire to lose weight (OR, 5.55; 95% CI, 1.86–16.80; p = .002), and current weight loss activities (OR, 5.49; 95% CI, 2.03–14.80; p < .001) remained significant even after controlling for age, gender, race, BMI, dietitian referral, and literacy level, where the outcome variables were patients’ understanding of the need to lose weight, desire to lose weight, or current weight loss activity, respectively, and the primary independent variable was patients’ recall of being counseled to lose weight. Independent variables also included age, gender, race, BMI, literacy level, and status of dietitian referral as covariables.
Resident–physicians’ weight loss counseling, although limited in scope, had a significant impact on patients’ understanding of obesity and their motivation for weight loss. This finding confirms a previous study that showed physicians’ advice influences patients’ understanding of health-related information and their behavior.15 Our study showed that patients who reported receiving weight loss counseling had a better understanding of the association between health and weight, the need to lose weight for improved health, and the benefit of weight loss. Physicians’ weight loss counseling also had a positive effect on patients’ motivation and behavior. Patients who recalled being counseled to lose weight were more likely to be motivated to lose weight, to have attempted previous weight loss, and to be engaged in current weight loss or maintenance activities.
Although physician counseling had a significant impact on public hospital patients’ knowledge and attitudes regarding weight and weight loss, 72% of patients received no specific weight loss recommendations from their resident–physicians. The percentage of all patients receiving weight loss counseling or recommendations in our study was higher than that reported for obese women attending community care clinics,16 but similar to that found among self-referred obese women in a university research clinic.17 Although small differences in the provision of weight loss counseling or recommendations may be due to differences in study setting and patient population, our results are consistent with national data that indicate both the rate and content of physician counseling about diet, exercise, and weight loss are inadequate.1,9,10 This is of particular concern considering the much higher prevalence of obesity and its related disorders among patients in public hospitals.11
Unhealthy diet and sedentary lifestyle are behavioral risk factors associated with the development of obesity. Prochaska's Transtheoretical Model of Behavior Change (Stages of Change) describes the behavioral stages that are prerequisites to changes in health behavior.13 Interventions matched to behavioral stage have documented effectiveness in encouraging exercise adoption and dietary modifications.18,19 The Stages of Change model has also been successfully applied to assess patients’ readiness for weight loss and to guide behavioral stage-appropriate weight loss interventions in obese patients.20–22 Approximately one third of the patients in our study were in the precontemplation/contemplation, preparation, or action/maintenance behavioral stage groupings. Other studies have documented more than 50% of overweight or obese patients from diverse settings as being in the action/maintenance behavioral stage.20,21,23 It is possible that differences in study population account for the differences in identified behavioral stage. Despite the reported differences in the percentage of patients in various behavioral stages, all our results suggest that patients are inconsistently prepared for weight loss. Physician counseling, tailored to the patient's stage of readiness for weight loss, may enhance the effectiveness of weight management recommendations.
Multiple barriers may prevent adequate weight loss counseling by primary care physicians in public hospitals. Focus-group findings from our study support previous findings that insufficient physician confidence, knowledge and counseling skills, as well as lack of time, resources and underuse of dietitians contribute to inadequate counseling on diet, physical activity, and weight loss.24–26 The major barriers to effective exercise, diet, and weight loss counseling identified in our study were similar to those reported in other physician surveys. A prominent barrier identified in our study and in studies conducted in university or community settings was that primary care physicians often feel inadequately prepared to provide this counseling.24,25,27,28 To remove this and other barriers, providing training in brief weight loss counseling for resident and primary care physicians may be necessary.
McArtor et al.29 have shown that weight management actions are taken more frequently for obese patients when obesity is recorded by resident–physicians on the medical problem list. The fact that the clinical diagnosis of obesity was documented in less than 15% of patients with a BMI of 30 or higher may have contributed to inadequate weight loss counseling rates in our study. Resident–physicians’ pessimism about the effectiveness of weight management at the primary care visit may also contribute to inadequate weight loss counseling. These results suggest that residents’ training should address both the guidelines of standard care for weight management and physicians’ attitudes about obesity and weight loss.
The results of our study support previous research that showed physicians provide weight loss counseling to patients with higher BMIs and to those with coronary artery disease risk factors, such as type 2 diabetes mellitus and dyslipidemia.9,30,31 Similar counseling patterns have been reported in patients receiving recommendations for exercise32 and dietary change.33 These results indicate that primary care physicians focus on the complications of obesity rather than on early identification and intervention of obesity and its sequelae. Although patients with higher BMIs and comorbid conditions should be intensively counseled, failure to counsel less obese and disease-free patients may represent a missed opportunity for primary prevention of obesity-related diseases, such as type 2 diabetes mellitus and coronary artery disease.
Nutritional and dietary consultation is one of the most useful ancillary services available in clinical practice for weight management.34 Our study documented a dietary referral rate of 63% in overweight and obese outpatients. However, further analysis supported previous findings that referral is initiated primarily for dietary therapy for type 2 diabetes mellitus and dyslipidemia rather than for weight control.34 Focus-group results in our study also revealed that physicians rarely relied on the dietitian for weight management.
Our study had several limitations. In this cross-sectional study, a causal relationship between patients’ recall of weight loss recommendations and their weight loss behavior could not be confirmed. Although we hypothesized that patients’ recall of weight loss recommendations influenced their understanding and weight loss behavior, it is also possible that patients with improved understanding of obesity and motivation for weight loss had better recall of recommendations. Furthermore, patients’ degree of understanding, motivation, and behavior regarding weight loss were self-reported during the exit interview, and therefore may have been overestimated. Our data did not allow further stratification to pair physicians’ demographic characteristics to patients’ responses individually. Finally, resident–physicians became aware of the general study purpose during the later phase of the study, possibly increasing weight management counseling rates. However, post hoc analysis revealed no difference in patient recall of weight-related recommendations over time.
Currently, few medical schools or residency programs incorporate training in obesity and weight loss counseling into their educational programs. Despite the fact that resident–physicians provided insufficient guidance on recommended weight loss strategies, the results of our study suggest that residents’ weight loss counseling had a significant impact on patients’ understanding of and motivation for weight loss. Resident training that addresses physicians’ knowledge, skills, and attitudes regarding obesity and weight loss may further enhance patients’ weight loss understanding and activity. Increased documentation of obesity as a distinct clinical diagnosis may improve weight loss counseling rates in public hospital primary care clinics.
Education is also needed on the primary prevention of obesity and its related disorders because resident–physicians appear to provide weight loss counseling to patients with higher BMIs and established comorbidities. Finally, identifying patients’ stage of readiness for weight loss may facilitate behavioral stage-specific weight loss counseling.
Incorporating a curriculum on counseling for lifestyle modification into residency education or continuing medical education for primary care physicians may increase the frequency and adequacy of weight loss counseling in primary care.
This study was funded in part by an educational grant from Hoffmann-LaRoche Pharmaceutical Company.
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