U.S. primary care physicians' diet-, physical activity-, and weight-related care of adult patients

Increasing Referrals to a YMCA-Based Diabetes Prevention Program: Effects of Electronic Referral System Modification and Provider Education in Federally Qualified Health Centers

Introduction

The Diabetes Prevention Program has been translated to community settings with varying success. Although primary care referrals are used for identifying and enrolling eligible patients in the Diabetes Prevention Program, little is known about the effects of strategies to facilitate and sustain eligible patient referrals using electronic health record systems.

Methods

To facilitate and sustain patient referrals, a modification to the electronic health record system was made and combined with provider education in 6 federally qualified health centers in the Bronx, New York. Referral data from April 2012 through November 2014 were analyzed using segmented regression analysis.

Results

Patient referrals increased significantly after the modification of the electronic health record system and implementation of the provider education intervention. Before the electronic system modification, 0 to 2 patients were referred per month. During the following year (September 2013 through August 2014), which included the provider education intervention, referrals increased to 1 to 9 per month and continued to increase to 5 to 11 per month from September through November 2014.

Conclusions

Modification of an electronic health record system coupled with a provider education intervention shows promise as a strategy to identify and refer eligible patients to community-based Diabetes Prevention Programs. Further refinement of the electronic system for facilitating referrals and follow-up of eligible patients should be explored.

Weight management practices and evidence for weight loss through primary care: a brief review

OBJECTIVE

The optimal role for primary care in the management of overweight and obesity is yet to be determined. This review examines current weight management practices in primary care and summarizes the evidence for weight loss interventions based in primary care settings.

RESEARCH DESIGN AND METHODS

PubMed was searched for literature on weight management in primary care published from 2000 onwards. Forty-one articles were included.

RESULTS

The prevalence of overweight and obesity is high among primary care patients, yet frequently under-diagnosed by general practitioners. When diagnosed, weight management practices are highly variable. Evidence supporting effective long term interventions for weight loss in primary care is limited. Consistency of outcome measures, explicit reporting of attrition rates and assessment of motivation at inclusion are critical for interpreting results.

CONCLUSIONS

An approach to weight management that includes the involvement of disciplines other than general practice appears to be more successful. Further research is required to determine the most effective approach in primary care.

Sleep Duration, Activity Levels, and Measures of Obesity in Adults

OBJECTIVE

The purpose of this study was to investigate sleep and activity as they relate to obesity measures of body mass index (BMI) and waist circumference (WC) in adults. Findings from recent studies have linked physical inactivity and short sleep with obesity.

DESIGN AND SAMPLE

A total of 337 subjects were collected from the 2009-2010 National Health and Nutrition Examination Survey (NHANES).

MEASURES

The sample was evaluated to determine if a relationship existed between sleep duration, activity levels, and measures of obesity.

RESULTS

Pearson r correlation revealed a significant positive relationship between WC and sedentary activity, r(318) = .168, p = .003. Analysis also showed a significant inverse association between sleep duration and WC, r(319) = -.113, p = .043. No statistical significance was found using BMI as the measure of obesity in relation to duration of sleep or activity level.

CONCLUSIONS

In support of recent literature, this study found duration of sleep and sedentary activity in adults may relate to the development of obesity as measured by WC.

Novel Longitudinal and Propensity Score Matched Analysis of Hands-On Cooking and Nutrition Education versus Traditional Clinical Education among 627 Medical Students

Background. Physicians are inadequately equipped to respond to the global obesity and nutrition-associated chronic disease epidemics. We investigated superiority of simulation-based medical education with deliberate practice (SBME-DP) hands-on cooking and nutrition elective in a medical school-based teaching kitchen versus traditional clinical education for medical students. Materials and Methods. A 59-question panel survey was distributed to an entire medical school twice annually from September 2012 to May 2014. Student diet and attitudes and competencies (DACs) counseling patients on nutrition were compared using conditional multivariate logistic regression, propensity score-weighted, and longitudinal panel analyses. Inverse-variance weighted meta-analysis (IVWM) was used for planned subgroup analysis by year and treatment estimates across the three methods. Results. Of the available 954 students, 65.72% (n = 627) unique students were followed to produce 963 responses. 11.32% (n = 109) of responses were from 84 subjects who participated in the elective. SBME-DP versus traditional education significantly improved fruit and vegetable diet (OR = 1.38, 95% CI: 1.07-1.79, p = 0.013) and attitudes (OR = 1.81, 95% CI: 1.40-2.35, p < 0.001) and competencies (OR = 1.72, 95% CI: 1.54-1.92, p < 0.001). Conclusions. This study reports for the first time superiority longitudinally for SBME-DP style nutrition education for medical students which has since expanded to 13 schools.

Primary Care Residents' Knowledge, Attitudes, Self-Efficacy, and Perceived Professional Norms Regarding Obesity, Nutrition, and Physical Activity Counseling

BACKGROUND

Obesity and being overweight are both significant risk factors for multiple chronic conditions. Primary care physicians are in a position to provide health behavior counseling to the majority of US adults, yet most report insufficient training to deliver effective counseling for obesity.

OBJECTIVE

To assess the degree to which residents training in adult primary care programs are prepared to provide obesity, nutrition, and physical activity (ONPA) counseling.

METHODS

Senior residents (postgraduate year [PGY]-3 and PGY-4) from 25 Ohio family medicine, internal medicine, and obstetrics and gynecology programs were surveyed regarding their knowledge about obesity risks and effective counseling, as well as their attitudes, self-efficacy, and perceived professional norms toward ONPA counseling. We examined summary scores, and used regression analyses to assess associations with resident demographics and training program characteristics.

RESULTS

A total of 219 residents participated (62% response rate). Mean ONPA counseling knowledge score was 50.8 (± 15.6) on a 0 to 100 scale. Specialty was associated with counseling self-efficacy (P < .001) and perceived norms (P = .002). Residents who reported having engaged in an elective rotation emphasizing ONPA counseling had significantly higher self-efficacy and more positive attitudes and professional norms scores.

CONCLUSIONS

Our findings suggest that primary care residents' knowledge of ONPA assessment and management strategies has room for improvement. Attitudes, self-efficacy, and perceived norms also are low and vary by training program characteristics. A deeper understanding of curricula associated with improved performance in these domains could inform interventions to enhance residents' ONPA counseling skills and prevent chronic disease.

Physician knowledge about and perceptions of obesity management

OBJECTIVE

Approximately 35% of US adults are obese. The purpose of this study was to assess the knowledge and practice patterns of primary care physicians (PCPs), endocrinologists (ENDOs), cardiologists (CARDs) and bariatricians (BARIs) regarding obesity.

METHODS

A case vignette survey was distributed to 1625 US-based PCPs, ENDOs, CARDs, and BARIs via email and fax in February 2013. Results were analysed with PASW Statistics 18.

RESULTS

Respondents included 100 PCPs, 100 ENDOs, 70 CARDs, and 30 BARIs. The majority agreed obesity is a disease as defined by the AMA, however, half of PCPs, ENDOs, and CARDs also agreed obesity results from a lack of self-control. Familiarity with select obesity guidelines was low. Nearly all respondents used body mass index for obesity screening. No consensus as to when to initiate weight-loss medication was observed. Many physicians expected a larger weight loss with pharmacotherapy than is realistic (∼ 30%) or were unsure (∼ 22%). A majority of PCPs, ENDOs and CARDs expected less excess weight loss with gastric bypass surgery than is realistic, BARIs had a more reasonable expectation.

CONCLUSIONS

Overall, respondents demonstrated knowledge gaps for obesity guidelines and pathophysiology and generally lacked understanding of obesity medication efficacy, safety and MOA.

Physical activity prescription among Mexican physicians: a structural equation analysis of the theory of planned behaviour

AIM

To describe the physical activity (PA) prescribing behaviour of Mexican primary care physicians and determine if the theory of planned behaviour (TPB) explains this behaviour.

METHODS

633 physicians (56% male, mean age 38 years) from 305 primary care clinics in Jalisco, Mexico self-reported PA prescription behaviour, PA involvement, attitude, subjective norm, perceived behavioural control (PBC) and intention related to PA prescription behaviour. Structural equation modelling (SEM) was employed.

RESULTS

48% of physicians reported they always ask patients about their PA, 33% provide verbal prescriptions, 6% provide written prescriptions, 8% refer patients to PA resources and 4% assess patient fitness. SEM analysis showed that the fit of the TPB model was satisfactory (RMSEA = 0.05, CFI = 0.98, SRMR = 0.05). The model explained 79% of the variance on intention (r(2) = 0.79, p < 0.05), and 14% of the variance on prescription behaviour (r(2) = 0.14, p < 0.05). Subjective norm (β = 0.73, p < 0.05) and attitude (β = 0.16, p < 0.05) explained behavioural intention, while PBC (β = 0.38, p < 0.05) and physician PA (β = 0.15, p < 0.05) explained prescription behaviour.

DISCUSSION

The TPB provided useful insight into physician prescription behaviour, although not all the theory tenets were supported. More research testing the TPB and other theories is needed to better understand psychosocial predictors of this behaviour.

CONCLUSION

Strategies aimed at improving physicians' perceived ability to prescribe PA and their own PA involvement seem worthwhile.

Clinical care providers' perspectives on body size and weight management among long-term cancer survivors

OBJECTIVE

To examine clinical care providers' perspectives on cancer survivors' body size and weight management.

STUDY DESIGN

In-depth, semi-structured, qualitative interviews.

METHODS

Interviews were conducted with 33 providers (eg. oncologists, surgeons, primary care providers, nurses, dietitians) across academic and community clinical settings. They were transcribed, coded, and analyzed thematically using constant comparative analysis.

RESULTS

Providers conceptualized weight in relation to acute treatment, cancer outcomes, or overall health/comorbidities. These patterns were reflected in their reported framing of weight discussions, although providers indicated that they counsel patients on weight to varying extents. Perspectives differed based on professional roles and patient populations. Providers reported that survivors are motivated to lose weight, particularly due to comorbidity concerns, but face numerous barriers to doing so.

CONCLUSION

Providers described survivor-level and capacity-level factors influencing survivors' weight management. Differences by provider type highlighted the role of provider knowledge, attitudes, and beliefs in clinical encounters. Opportunities for research and intervention include developing and disseminating evidence-based clinical resources for weight management among cancer survivors, addressing capacity barriers, and exploring communication strategies at interpersonal and population levels.

Including lifestyle medicine in undergraduate medical curricula

PURPOSE

Currently, there is no model to integrate the discipline of lifestyle medicine (LM) into undergraduate medical education. Furthermore, there are no guidelines, validated assessment tools, or evaluation or implementation plans in place.

BACKGROUND

The World Health Organization predicts that by 2020, two-thirds of disease worldwide will be the result of poor lifestyle choices. Fewer than 50% of US primary care physicians routinely provide specific guidance on nutrition, physical activity, or weight control.

METHODS

We are establishing a plan to integrate LM into medical school education in collaboration with the investing stakeholders, including medical school deans and students, medical curriculum developers and researchers, medical societies, governing bodies, and policy institutes. Three planning and strategy meetings are being held to address key areas of focus - with a particular interest in nutrition, physical activity, student self-care, and behavior change - to develop specific implementation guidelines and landmarks.

RESULTS

After the first two meetings, the proposed areas of focus were determined to be: 1) supporting of deans and key personnel, 2) creation of federal and state policy commitments, 3) use of assessment as a driver of LM, 4) provision of high-quality evidence-based curricular material on an easily navigated site, and 5) engaging student interest. Implementation strategies for each focus area will be addressed in an upcoming planning meeting in early 2015.

CONCLUSION

This initiative is expected to have important public health implications by efficiently promoting the prevention and treatment of non-communicable chronic disease with a scalable and sustainable model to educate physicians in training and practice.

Factors that influence physicians' and medical students' confidence in counseling patients about physical activity

Less than half of US adults and two-thirds of US high school students do not meet current US guidelines for physical activity. We examined which factors promoted physicians' and medical students' confidence in counseling patients about physical activity. We established an online exercise survey targeting attending physicians, resident and fellow physicians, and medical students to determine their current level of physical activity and confidence in counseling patients about physical activity. We compared their personal level of physical activity with the 2008 Physical Activity Guidelines of the US Department of Health and Human Services (USDHHS). We administered a survey in 2009 and 2010 that used the short form of the International Physical Activity Questionnaire. A total of 1,949 individuals responded to the survey, of whom 1,751 (i.e., 566 attending physicians, 138 fellow physicians, 806 resident physicians, and 215 medical students) were included in this analysis. After adjusting for their BMI, the odds that physicians and medical students who met USDHHS guidelines for vigorous activity would express confidence in their ability to provide exercise counseling were more than twice that of physicians who did not meet these guidelines. Individuals who were overweight were less likely to be confident than those with normal BMI, after adjusting for whether they met the vigorous exercise guidelines. Physicians with obesity were even less likely to express confidence in regards to exercise counseling. We conclude that physicians and medical students who had a normal BMI and met vigorous USDHHS guidelines were more likely to feel confident about counseling their patients about physical activity. Our findings suggest that graduate medical school education should focus on health promotion in their students, as this will likely lead to improved health behaviors in their students' patient populations.

Perceived judgment about weight can negatively influence weight loss: a cross-sectional study of overweight and obese patients

OBJECTIVE

To examine the association between patient-perceived judgments about weight by primary care providers (PCPs) and self-reported weight loss.

METHODS

We conducted a national internet-based survey of 600 adults engaged in primary care with a body mass index (BMI)≥25 kg/m(2) in 2012. Our weight loss outcomes included attempted weight loss and achieved ≥10% weight loss in the last 12 months. Our independent variable was "feeling judged about my weight by my PCP." We created an interaction between perceiving judgment and PCP discussing weight loss as an independent variable. We conducted a multivariate logistic regression model adjusted for patient and PCP factors using survey weights.

RESULTS

Overall, 21% perceived that their PCP judged them about their weight. Respondents who perceived judgment were significantly more likely to attempt weight loss [odds ratios (OR) 4.67, 95% confidence interval (CI) 1.96-11.14]. They were not more likely to achieve ≥10% weight loss [OR 0.87, 95%CI 0.42-1.76]. Among patients whose PCPs discussed weight loss, 20.1% achieved ≥10% weight loss if they did not perceive judgment by their PCP as compared to 13.5% who perceived judgment.

CONCLUSIONS

Weight loss discussions between patients and PCPs may lead to greater weight loss in relationships where patients do not perceive judgment about their weight.

Healthcare provider accuracy at estimating women's BMI and intent to provide counseling based on appearance alone

OBJECTIVE

To assess healthcare providers' ability to estimate women's body mass index (BMI) based on physical appearance and determine the prevalence of, and barriers to, weight-related counseling.

METHODS

A web-based survey was distributed to healthcare providers ("participants") at a university-based hospital and contained photographs of anonymous women ("photographed women (PW)") as well as questions regarding participant demographics. Participants were asked to estimate BMI category based on physical appearance, state whether they would provide weight-loss counseling for each PW and identify barriers to counseling.

RESULTS

One hundred forty-two participants completed the survey. BMI estimations were poor among all participants, with an overall accuracy of only 41% and a large proportion of underestimations. Standardization of PW clothing did not improve accuracy; 41% for own clothing versus 40% for scrubs, P = 0.2. BMI assessments were more accurate for Caucasian versus African American PW (45% versus 36%, P < 0.001) and PW with normal weight (84%) and obesity III (38%) compared to PW with mid-range BMI (P < 0.001). Although the frequency of weight loss counseling was positively associated with PW BMI, participants only intended to counsel 69% of overweight and obese PW. The most commonly cited reason for lack of counseling was time constraints (54%).

CONCLUSIONS

Healthcare providers are inaccurate at appearance-based BMI categorization and thus, BMI should be routinely calculated in order to improve identification of those in need of counseling. When appropriately identified, time constraints may prevent practitioners from providing appropriate weight-loss counseling-further complicating the already difficult task of fighting obesity.

Dutch General Practitioners' weight management policy for overweight and obese patients

BACKGROUND

General practitioners (GPs) can play an important role in both the prevention and management of overweight and obesity. Current general practice guidelines in the Netherlands allow room for GPs to execute their own weight management policy.

OBJECTIVE

To examine GPs' current weight management policy and the factors associated with this policy.

METHODS

800 Dutch GPs were asked to complete a questionnaire in December 2012. The questionnaire items were based on the Dutch Obesity Standard for GPs. The data were analyzed by means of descriptive statistics and multiple linear regression analyses in 2013.

RESULTS

In total, 307 GPs (39.0%) responded. Most respondents (82.9%) considered weight management as part of their responsibility for providing care. GPs aged <48 years discussed weight less frequent. Next, weight is less frequently discussed with patients without weight-related comorbidities or with moderately overweight patients compared to obese patients. On average, 47.7% of the GPs reported to refer obese patients to a weight management professional, preferably a dietitian (98.3%). GPs with a BMI ≥ 25 kg/m(2) were less likely to refer obese patients. In addition, GPs who had frequent contact with a dietitian were more likely to refer obese patients.

CONCLUSIONS

In the context of General Practice and preventive medicine, GPs' discussion of weight and the variety of obesity-determinants with their moderately overweight patients deserves more attention, especially from younger GPs. Strengthening interdisciplinary collaboration between GPs and dietitians could increase the referral percentage for dietary treatment.

Organization of Primary Care Practice for Providing Energy Balance Care

Purpose.

Primary care physicians (PCPs) may not adequately counsel or monitor patients regarding diet, physical activity, and weight control (i.e., provide energy balance care). We assessed the organization of PCPs' practices for providing this care.

Design.

The study design was a nationally representative survey conducted in 2008.

Setting.

The study setting was U.S. primary care practices.

Subjects.

A total of 1740 PCPs completed two sequential questionnaires (response rate, 55.5%).

Measures.

The study measured PCPs' reports of practice resources, and the frequency of body mass index assessment, counseling, referral for further evaluation/management, and monitoring of patients for energy balance care.

Analysis.

Descriptive statistics and logistic regression modeling were used.

Results.

More than 80% of PCPs reported having information resources on diet, physical activity, or weight control available in waiting/exam rooms, but fewer billed (45%), used reminder systems (< 30%), or received incentive payments (3%) for energy balance care. A total of 26% reported regularly assessing body mass index and always/often providing counseling as well as tracking patients for progress related to energy balance. In multivariate analyses, PCPs in practices with full electronic health records or those that bill for energy balance care provided this care more often and more comprehensively. There were strong specialty differences, with pediatricians more likely (odds ratio, 1.78; 95% confidence interval, 1.26–2.51) and obstetrician/gynecologists less likely (odds ratio, 0.28; 95% confidence interval, 0.17–0.44) than others to provide energy balance care.

Conclusion.

PCPs' practices are not well organized for providing energy balance care. Further research is needed to understand PCP care-related specialty differences.

Nurses' self-efficacy and practices relating to weight management of adult patients: a path analysis

BACKGROUND

Health professionals play a key role in the prevention and treatment of excess weight and obesity, but many have expressed a lack of confidence in their ability to manage obese patients with their delivery of weight-management care remaining limited. The specific mechanism underlying inadequate practices in professional weight management remains unclear. The primary purpose of this study was to examine a self-efficacy theory-based model in understanding Registered Nurses' (RNs) professional performance relating to weight management.

METHODS

A self-report questionnaire was developed based upon the hypothesized model and administered to a convenience sample of 588 RNs. Data were collected regarding socio-demographic variables, psychosocial variables (attitudes towards obese people, professional role identity, teamwork beliefs, perceived skills, perceived barriers and self-efficacy) and professional weight management practices. Structural equation modeling was conducted to identify correlations between the above variables and to test the goodness of fit of the proposed model.

RESULTS

The survey response rate was 71.4% (n = 420). The respondents reported a moderate level of weight management practices. Self-efficacy directly and positively predicted the weight management practices of the RNs (β = 0.36, p < 0.01), and fully or partially mediated the relationships between perceived skills, perceived barriers, professional role identity and teamwork beliefs and weight management practices. The final model constructed in this study demonstrated a good fit to the data [χ2 (14) =13.90, p = 0.46; GFI = 0.99; AGFI = 0.98; NNFI = 1.00; CFI = 1.00; RMSEA = 0.00; AIC = 57.90], accounting for 38.4% and 43.2% of the variance in weight management practices and self-efficacy, respectively.

CONCLUSIONS

Self-efficacy theory appears to be useful in understanding the weight management practices of RNs. Interventions targeting the enhancement of self-efficacy may be effective in promoting RNs' professional performance in managing overweight and obese patients.

Physical activity promotion in the health care system

Physical activity (PA) and exercise training (ET) have great potential in the prevention, management, and rehabilitation of a variety of diseases, but this potential has not been fully realized in clinical practice. The health care system (HCS) could do much more to support patients in increasing their PA and ET. However, counseling on ET is not used widely by the HCS owing partly to attitudes but mainly to practical obstacles. Extensive searches of MEDLINE, the Cochrane Library, the Database of Abstracts of Reviews of Effects, and ScienceDirect for literature published between January 1, 2000, and January 31, 2013, provided data to assess the critical characteristics of ET counseling. The evidence reveals that especially brief ET counseling is an efficient, effective, and cost-effective means to increase PA and ET and to bring considerable clinical benefits to various patient groups. Furthermore, it can be practiced as part of the routine work of the HCS. However, there is a need and feasible means to increase the use and improve the quality of ET counseling. To include PA and ET promotion as important means of comprehensive health care and disease management, a fundamental change is needed. Because exercise is medicine, it should be seen and dealt with in the same ways as pharmaceuticals and other medical interventions regarding the basic and continuing education and training of health care personnel and processes to assess its needs and to prescribe and deliver it, to reimburse the services related to it, and to fund research on its efficacy, effectiveness, feasibility, and interactions and comparability with other preventive, therapeutic, and rehabilitative modalities. This change requires credible, strong, and skillful advocacy inside the medical community and the HCS.

Weight loss success in metabolic syndrome by telephone interventions: results from the SHINE Study

BACKGROUND

The Diabetes Prevention Program (DPP) intensive lifestyle intervention resulted in significant weight loss, reducing the development of diabetes, but needs to be adapted to primary care provider (PCP) practices.

OBJECTIVES

To compare a DPP-translation using individual (IC) vs. conference (CC) calls delivered by PCP staff for the outcome of percent weight loss over 2 years.

DESIGN

Randomized clinical trial.

SETTING

Five PCP sites.

PARTICIPANTS

Obese patients with metabolic syndrome, without diabetes (IC, n = 129; CC, n = 128).

INTERVENTION

Telephone delivery of the DPP Lifestyle Balance intervention [16-session core curriculum in year 1, 12-session continued telephone contact in year 2 plus telephone coaching sessions (dietitians).

MAIN MEASURES

Weight (kg), body mass index (BMI), and waist circumference.

KEY RESULTS

BASELINE DATA

age = 52 years, BMI = 39 kg/m(2), 75 % female, 85 % non-Hispanic White, 13 % non-Hispanic Black, and 48 % annual incomes <$40,000/year. In the intention-to-treat analyses at year 2, mean percent weight loss was -5.6 % (CC, p < 0.001) and -1.8 % (IC, p = 0.046) and was greater for CC than for IC (p = 0.016). At year 2, mean weight loss was 6.2 kg (CC) and 2.2 kg (IC) (p < 0.001). There was similar weight loss at year 1, but between year 1 and year 2 CC participants continued to lose while IC participants regained. At year 2, 52 % and 43 % (CC) and 29 % and 22 % (IC) of participants lost at least 5 % and 7 % of initial weight. BMI also decreased more for CC than IC (-2.1 kg/m(2) vs. -0.8 kg/m(2) p < 0.001). Waist circumference decreased by 3.1 cm (CC) and 2.4 cm (IC) at year 2. Completers (≥9 of 16 sessions; mean 13.3 sessions) lost significantly more weight than non-completers (mean 4.3 sessions).

CONCLUSIONS

PCP staff delivery of the DPP lifestyle intervention by telephone can be effective in achieving weight loss in obese people with metabolic syndrome. Greater weight loss may be attained with a group telephone intervention.

Potential value of health information exchange for people with epilepsy: crossover patterns and missing clinical data

CONTEXT

For people with epilepsy, the potential value of health information exchange (HIE) is unknown.

METHODS

We reviewed two years of clinical encounters for 8055 people with epilepsy from seven Manhattan hospitals. We created network graphs illustrating crossover among these hospitals for multiple encounter types, and calculated a novel metric of care fragmentation: "encounters at risk for missing clinical data."

RESULTS

Given two hospitals, a median of 109 [range 46 - 588] patients with epilepsy had visited both. Due to this crossover, recent, relevant clinical data may be missing at the time of care frequently (44.8% of ED encounters, 34.5% inpatient, 24.9% outpatient, and 23.2% radiology). Though a smaller percentage of outpatient encounters were at risk for missing data than ED encounters, the absolute number of outpatient encounters at risk was three times higher (14,579 vs. 5041).

CONCLUSION

People with epilepsy may benefit from HIE. Future HIE initiatives should prioritize outpatient access.

qDIET: toward an automated, self-sustaining knowledge base to facilitate linking point-of-sale grocery items to nutritional content

The United States, indeed the world, struggles with a serious obesity epidemic. The costs of this epidemic in terms of healthcare dollar expenditures and human morbidity/mortality are staggering. Surprisingly, clinicians are ill-equipped in general to advise patients on effective, longitudinal weight loss strategies. We argue that one factor hindering clinicians and patients in effective shared decision-making about weight loss is the absence of a metric that can be reasoned about and monitored over time, as clinicians do routinely with, say, serum lipid levels or HgA1C. We propose that a dietary quality measure championed by the USDA and NCI, the HEI-2005/2010, is an ideal metric for this purpose. We describe a new tool, the quality Dietary Information Extraction Tool (qDIET), which is a step toward an automated, self-sustaining process that can link retail grocery purchase data to the appropriate USDA databases to permit the calculation of the HEI-2005/2010.

Comparison of physical activity levels in physicians and medical students with the general adult population of the United States

OBJECTIVE

Physicians who are physically fit have a higher likelihood of counseling their patients about physical activity. We sought to determine if the amount of physical activity in physicians and medical students differs from the general adult population of the United States and if geographic differences in physical activity levels exist.

METHODS

A cross-sectional survey was distributed to physicians and medical students throughout the United States to determine their level of physical activity according to US Department of Health and Human Services (DHHS) 2008 guidelines; data were collected from participants from June 2009 through January 2010. Our data set was compared with physical activity data from the Centers for Disease Control and Prevention (CDC) and we used geographic regions defined by the US Census Bureau.

RESULTS

Our survey respondents contained 631 attending physicians, 159 fellow physicians, 897 resident physicians, and 262 medical students. Only 64.5% of the general US adult population meets DHHS guidelines for physical activity, but 78% of the survey participants fulfilled the guidelines. The percentage of US adults who do not engage in leisure-time physical activity is 25.4% compared with 5.8% of survey participants. Survey respondents in the southern region had the lowest physical activity levels and participants in the western region had the highest levels.

CONCLUSION

Physicians and medical students engage in more physical activity than the general US adult population. Regional differences in the general population's physical activity also persisted in physicians and medical students. Therefore, physicians who complete less physical activity may be less likely to encourage patients to engage in physical activity in geographic areas where the adult population is less active.

Physical activity counseling in primary health care in Brazil: a national study on prevalence and associated factors

Background

The aim of this study was to determine the prevalence and correlates of physical activity counseling among physicians and nurses working in primary health care in Brazil.

Methods

A phone survey was carried out in 2011 with professionals working in primary health care in Brazil. The target sample consisted of 1,600 randomly selected primary care units covering all regions of the country. We successfully interviewed 529 professionals within the sampled units; 182 physicians and 347 nurses. The overall response rate was 49.6%. Multivariable logistic regression was used to estimate correlates of counseling in the whole sample and separately for physicians and nurses.

Results

The prevalence of regular physical activity counseling for at least six months was 68.9% (95% CI 64.9; 72.8) and was significantly higher among physicians compared to nurses (p < 0.05). Most professionals (93.2%) interviewed were unfamiliar with current physical activity recommendations for health. In the adjusted analysis, physical activity counseling was more frequent among those who report assessing patient’s physical activity (OR = 2.16; 95% CI 1.41; 3.29), those reporting that lack of time was not a barrier for counseling (OR = 0.62 95% CI 0.42-0.93), those who felt prepared to provide physical activity counseling (OR = 2.34; 95% CI 1.50-3.66), and those working at primary care units offering physical activity programs for patients (OR = 2.06; 95% CI 1.33-3.20). In the stratified analysis, only assessing patient’s physical activity was a significant correlate among physicians whereas assessing patient’s physical activity, feeling prepared to provide counseling and working in units with physical activity interventions were significant correlates among nurses.

Conclusions

Physicians and nurses deemed physical activity counseling of great importance in primary health care in Brazil. However, in order to increase the quality of counseling and the number of professionals engaging in this activity, these health teams require greater knowledge about physical activity (global recommendations for health) as well as training on the application of instruments for assessing physical activity. Moreover, sufficient time must be allowed during consultations for the counseling process, and physical activity promotion programs should be implemented within the primary health care units.

District nurses' self-reported clinical activities, beliefs about and attitudes towards obesity management

AIM

To describe district nurses' self-reported clinical activities, beliefs about and attitudes towards obesity management; and to examine associations between the variables.

BACKGROUND

Obesity is increasing worldwide and primary care could play a central role in the management.

METHODS

Questionnaire data were collected from 247 nurses in 33 centres.

RESULTS

The most common activities performed weekly were; advice about physical activity (40.1%) and general lifestyle advice (34.8%). However, nearly one third seldom/never performed these activities. Approximately half seldom/never performed BMI assessment and even fewer waist circumference (78.1%). Values for the factors Importance of obesity and Personal effectiveness were skewed towards a positive view and Negative view close to neutral. Multivariate analysis revealed that nurses with specialized tasks, longer working experience and higher perceived personal effectiveness performed more clinical activities.

CONCLUSION

Managers need to make efforts to engage all personnel in obesity management; and strategies to increase self-efficacy are called for.

Interventions for lifestyle changes to promote weight reduction, a randomized controlled trial in primary health care

Background

Overweight and obesity are growing public health problems in high income countries and is now growing at a dramatic pace in low and middle income countries, particularly in urban settings. The aim of this trial was to examine the effects of a weight reduction program in adults and to determine whether or not a more extensive intervention was superior to ordinary care.

Methods

Patients seeking advice for overweight/obesity or illness related to overweight/obesity at eight primary health care centers in Sweden were randomized either to intervention or control care groups with both groups given dietary advice and individualized information on increased regular physical activity. In the intervention group advice was more extensive and follow-up more frequent than in the control group during the study period of two years. Main outcome measure was reduction in body weight of five percent or more from study start.

Results

From October 2004 to April 2006, 133 patients, 67 in the intervention group and 66 in the control group, were randomized over a period of 18 months. Target weight was achieved at 12 months by 26.7% of the patients in the intervention group compared with 18.4% in the control group (p = 0.335). There was an average absolute weight loss of 2.5 kg in the intervention group and 0.8 kg in the control group at 12 months as compared with the weight at study entry. There were no significant differences between the groups in quality of life, blood glucose and lipids. At 24 months target weight was achieved in 21.9% versus 15.6%, with an average weight reduction of 1.9 kg and 1.2 kg in the two groups, respectively.

Conclusions

Promotion of a diet with limited energy intake, appropriate composition of food and increased physical activity had limited effects on body weight in a Swedish primary care setting. More extensive advice and more frequent visits made no significant difference to the outcome.

Trial registration

ClinicalTrial.gov: NCT01606917

Weight discrimination and bullying

Despite significant attention to the medical impacts of obesity, often ignored are the negative outcomes that obese children and adults experience as a result of stigma, bias, and discrimination. Obese individuals are frequently stigmatized because of their weight in many domains of daily life. Research spanning several decades has documented consistent weight bias and stigmatization in employment, health care, schools, the media, and interpersonal relationships. For overweight and obese youth, weight stigmatization translates into pervasive victimization, teasing, and bullying. Multiple adverse outcomes are associated with exposure to weight stigmatization, including depression, anxiety, low self-esteem, body dissatisfaction, suicidal ideation, poor academic performance, lower physical activity, maladaptive eating behaviors, and avoidance of health care. This review summarizes the nature and extent of weight stigmatization against overweight and obese individuals, as well as the resulting consequences that these experiences create for social, psychological, and physical health for children and adults who are targeted.

Nutrition and physical activity guidance practices in general practice: a critical review

OBJECTIVE

The aim of this critical review is to provide insight into the main outcomes of research on communication about nutrition and/or physical activity between GPs and patients for prevention or treatment of overweight and obesity.

METHODS

Relevant studies were identified by a computerized search of multiple electronic databases (MEDLINE, PsycINFO) for all available papers between 1 January 1995 and 1 January 2012. In addition, two independent reviewers judged all studies on ten quality criteria.

RESULTS

In total, 41 studies were retrieved. More studies were found about the guidance of obese patients than of overweight patients. The most common weight guidance practice was discussion of weight. The range of communication strategies for nutrition showed to be more diverse than for physical activity. Twelve studies were considered as high-quality studies, 18 were having medium quality, and 11 were seen as low quality.

CONCLUSION

We reflected on the fact that the content of advice about nutrition and physical activity was quite general. GPs' provision of combined lifestyle advice to overweight and obese patients seems to be rather low.

PRACTICE IMPLICATIONS

Observational research is needed to unravel the quality of the advice given by GPs to overweight and obese patients.

National survey of US primary care physicians' perspectives about causes of obesity and solutions to improve care

OBJECTIVE

To describe physician perspectives on the causes of and solutions to obesity care and identify differences in these perspectives by number of years since completion of medical school.

DESIGN

National cross-sectional online survey from 9 February to 1 March 2011.

SETTING

USA.

PARTICIPANTS

500 primary care physicians.

MAIN MEASURES

We evaluated physician perspectives on: (1) causes of obesity, (2) competence in treating obese patients, (3) perspectives on the health professional most qualified to help obese patients lose or maintain weight and (4) solutions for improving obesity care.

RESULTS

Primary care physicians overwhelmingly supported additional training (such as nutrition counselling) and practice-based changes (such as having scales report body mass index) to help them improve their obesity care. They also identified nutritionists/dietitians as the most qualified providers to care for obese patients. Physicians with fewer than 20 years since completion of medical school were more likely to identify lack of information about good eating habits and lack of access to healthy food as important causes of obesity. They also reported feeling relatively more successful helping obese patients lose weight. The response rate for the survey was 25.6%.

CONCLUSIONS

Our results indicate a perceived need for improved medical education related to obesity care.

Knowledge of energy balance guidelines and associated clinical care practices: the U.S. National Survey of Energy Balance Related Care among Primary Care Physicians

OBJECTIVE

To assess primary care physicians' (PCPs) knowledge of energy balance related guidelines and the association with sociodemographic characteristics and clinical care practices.

METHOD

As part of the 2008 U.S. nationally representative National Survey of Energy Balance Related Care among Primary Care Physicians (EB-PCP), 1776 PCPs from four specialties who treated adults (n=1060) or children and adolescents (n=716) completed surveys on sociodemographic information, knowledge of energy balance guidelines, and clinical care practices.

RESULTS

EB-PCP response rate was 64.5%. For PCPs treating children, knowledge of guidelines for healthy BMI percentile, physical activity, and fruit and vegetables intake was 36.5%, 27.0%, and 62.9%, respectively. For PCPs treating adults, knowledge of guidelines for overweight, obesity, physical activity, and fruit and vegetables intake was 81.4%, 81.3%, 70.9%, and 63.5%, respectively. Generally, younger, female physicians were more likely to exhibit correct knowledge. Knowledge of weight-related guidelines was associated with assessment of body mass index (BMI) and use of BMI-for-age growth charts.

CONCLUSION

Knowledge of energy balance guidelines among PCPs treating children is low, among PCPs treating adults it appeared high for overweight and obesity-related clinical guidelines and moderate for physical activity and diet, and was mostly unrelated to clinical practices among all PCPs.

Pediatricians' and family physicians' weight-related care of children in the U.S

BACKGROUND

Few national data exist to assess primary care physicians' (PCPs') clinical practices with regard to childhood obesity.

PURPOSE

To survey pediatricians and family practice physicians regarding their assessment, counseling, and management of diet, physical activity, and weight status among pediatric patients in the primary care setting.

METHODS

A nationally representative cross-sectional survey of pediatricians and family practice physicians sampled from the American Medical Association (AMA) Masterfile was conducted in 2008 and analyzed in 2010. Outcomes included physicians' self-reported practice behaviors regarding assessments of pediatric patients' weight status, counseling of diet and physical activity, and referrals and follow-ups.

RESULTS

Response rate excluding physicians listed as "no-contact" by the AMA was 73.7% among pediatricians and 66.9% among family physicians. Less than 50% of all PCPs assessed BMI percentiles regularly in children. Eighteen percent of all PCPs reported referring children for further evaluation or management. Fifty-eight percent of all PCPs reported never, rarely, or only sometimes tracking patients over time concerning weight or weight-related behaviors. Pediatricians were more likely than family physicians to assess weight status and provide behavioral counseling (p's<0.001).

CONCLUSIONS

Active PCP participation in assessing or managing childhood obesity in the primary care setting appears low relative to the frequency of the problem in the U.S. Interventions to reduce the barriers to physician engagement in the assessment and management of healthy lifestyles are needed to prevent and control childhood obesity.