Trends in professional advice to lose weight among obese adults, 1994 to 2000

A Conceptual Model for Mobile Health-enabled Slow Eating Strategies

Ingestive behaviors (IBs) (eg, bites, chews, oral processing, swallows, pauses) have meaningful roles in enhancing satiety, promoting fullness, and decreasing food consumption, and thus may be an underused strategy for obesity prevention and treatment. Limited IB monitoring research has been conducted because of a lack of accurate automated measurement capabilities outside laboratory settings. Self-report methods are used, but they have questionable validity and reliability. This paper aimed to present a conceptual model in which IB, specifically slow eating, supported by technological advancements, contributes to controlling hedonic and homeostatic processes, providing an opportunity to reduce energy intake, and improve health outcomes.

Weight management counseling experiences of first year medical students before starting medical school and their self-perceived impact on treating patients with obesity

Physicians can play a vital role in counseling patients on overweight and obesity. This secondary analysis examined whether experiences in patient care specific to weight management before starting medical school were associated with students' intentions and confidence to provide weight management counseling (WMC) to patients who have overweight or obesity, and perceived impact as future physicians on patients' motivation to manage weight. First-year medical students (n = 1305) in the entering class of 2020 at eight medical schools nationwide completed questions relating to their prior experiences in patient care and WMC using the 5As. Also assessed were their intentions to treat patients with overweight or obesity, and confidence in counseling patients to help manage their weight. Over half the students (58.3%) who completed the survey had prior experience in patient care and nearly half (47.4%) began medical school with prior WMC experiences. Prior experiences correlated positively with higher confidence in performing WMC and students' intentions to treat patients with overweight or obesity. Given the relatively high rates of exposure to some type of weight management or lifestyle counseling among students before enrolling in medical school, the curriculum could build on established student interest and experience by offering treatment strategies including counseling for patients with overweight and obesity. By making prior experiences advantageous for admission, medical schools could gravitate towards admitting students who have brief but valuable insights about weight management in health care, thus increasing the possibility of filling important gaps.

Healthy Lifestyle Counseling by Healthcare Practitioners: A Time to Event Analysis

INTRODUCTION

Medical societies have heavily prioritized preventive care, as evidenced by numerous best practice guidelines supporting counseling patients on lifestyle factors. This report examines preventive counseling by healthcare providers in a rural healthcare system. We utilized electronic medical records to determine whether patient characteristics and chronic conditions were predictors of preventive counseling, and what the average time-interval was before a patient received this counseling.

METHODS

Medical records from a cohort of 395 subjects participating in the 1999 Bassett Health Census Survey were reviewed for documented counseling with respect to smoking cessation, weight management, physical activity, and health condition-related diets (anti-hypertensive and diabetic diets).

RESULTS

Our analyses revealed extensive delays in counseling for smoking cessation among smokers (median time to counseling = 4.2 years), for weight management among the obese (median time = 4.8 years), and for physical activity for all subjects (median time = 10.9 years). For those with diabetes, a median time of 7.5 years passed before being counseled on a diabetic diet. Hypertensive diet counseling did not occur for more than 50% of hypertensives.

CONCLUSION

In this population, we did not find documentation of lifestyle counseling that was in compliance with current guidelines for any of the lifestyle factors. The measurement of actual delay times provides further support for the position that preventive efforts of health care providers need to be improved.

Healthcare provider counselling for weight management behaviours among adults with overweight or obesity: a cross-sectional analysis of National Health and Nutrition Examination Survey, 2011-2018

OBJECTIVES

To determine if adults with overweight or obesity received counselling from their healthcare providers (HCPs) to lose weight and/or adopt healthful behaviours associated with weight loss, and whether they took action on their HCPs' recommendations.

DESIGN

Cross-sectional analysis of 2011-2018 National Health and Nutrition Examination Survey (NHANES) data.

SAMPLE

NHANES respondents aged 18+ who were overweight/obese and had seen an HCP in the previous 12 months (n=13 158).

METHODS

Respondents reported if their HCPs recommended they control/lose weight, increase exercise/physical activity (PA) and/or reduce fat/calorie intake, and if they adopted the offered recommendation(s). Weighted logistic regression models examined receipt of HCP counselling by sex, age, race/ethnicity, and weight status accounting for demographic characteristics and complex sampling. Similar analyses examined reported adoption of HCPs' recommendations.

RESULTS

The sample was 53.1% women, 45.0% were overweight and 55.0% had obesity. In total, 40.4% received counselling to control/lose weight, 49.5% to increase exercise/PA and 38.9% to reduce fat/calorie intake. The following groups were less likely (p<0.001) to receive counselling: men; younger adults (aged 18-39) versus middle-aged (aged 40-64) and older adults (aged 65+); White versus Black and Hispanic respondents; overweight respondents versus respondents with obesity. Approximately half of those advised to make changes reported doing so (53.6% controlled/lost weight, 57.3% increased exercise/PA, 51.8% reduced fat/calorie intake). Differences in the adoption of recommendations were identified by sex, age group, race/ethnicity and weight status (all p<0.05); women, middle-aged and older adults, Black and Hispanic respondents and individuals with obesity were more likely to adopt one or more recommendations.

CONCLUSION

Most respondents did not receive HCP counselling, and approximately half of those who received counselling reported taking action. HCPs may need training to provide counselling and to offer recommendations tailored to the social contexts of populations less likely to adopt weight control related recommendations.

Physicians' political party affiliation and clinical management of obesity

Studies have documented that few patients with obesity receive evidence-based care. One provider characteristic that may impact clinical obesity care, but that has been under studied to date, is political party affiliation. This study sought to evaluate how primary care physicians (PCPs) report managing patients with obesity and assess whether there are differences between Democratic and Republican PCPs. This was a secondary analysis of a cross-sectional survey of 225 PCPs registered to vote as Democrats or Republicans in 29 US States. After reading a patient vignette, the PCPs reported the following outcomes: likelihood of documenting obesity in the medical record; likelihood of discussing obesity with the patient; and likelihood of engaging in eight different obesity management options. Almost all PCPs reported they would document obesity in the medical record (Republican = 97.6%, Democrat = 94.3%) and discuss it further (Republican = 95.2%, Democrat = 92.2%). Among eight obesity management options, PCPs were least likely to say they would prescribe medication (3.9%) or refer the patient to counselling (24.0%), regardless of political affiliation. Republicans were more likely to report that they would inquire about the time course of obesity (73.4% v. 56.2%, P = 0.012) and discuss health risks of obesity (91.0% vs 78.3%, P = .018). Republican and Democratic PCPs report some differences in managing patients with obesity, suggesting that political beliefs may play a role in some clinical care.

Provider Advice and Patient Perceptions on Weight Across Five Health Systems

INTRODUCTION

To improve the management of overweight and obesity in the primary care setting, an analysis of patient perceptions of weight status and predictors of weight loss attempts for those with overweight and obesity is needed.

METHODS

Primary care patients (n=949) across 5 health systems in the Mid-Atlantic region of the U.S. were surveyed in 2015; data analysis was performed in 2018. Survey data was combined with data via the electronic health record to understand patients' perceptions of weight, factors associated with weight loss efforts, and provider counseling practices.

RESULTS

Most participants with overweight or obesity perceived themselves as weighing too much and reported trying to lose weight. Furthermore, most participants with obesity reported receiving advice to lose weight by a provider in the past 12 months. However, less than half of patients with overweight reported receiving advice to lose weight, maintain weight, or develop healthy eating and physical activity patterns from a health professional in the past 12 months. Among participants with overweight and obesity, multivariable logistic regression analysis demonstrated that the perception of being overweight and receiving healthcare advice to lose weight had the highest odds of reporting attempted weight loss (OR=5.5, 95% CI=2.7, 11.2 and OR=3.9, 95% CI=1.9, 7.9, respectively).

CONCLUSIONS

The findings emphasize the importance of provider attention to weight management counseling and identifies patients with overweight as needing increased attention by providers.

Trends in US adults with overweight and obesity reporting being notified by doctors about body weight status, 1999-2016

BACKGROUND AND AIMS

Engaging healthcare providers (HCPs) is critical for early identification of overweight and obesity. The aim of this study is to describe the trend in clinicians' adherence to clinical recommendations to discuss body weight status with adults with overweight and obesity.

METHODS AND RESULTS

We analyzed the data of adults aged 20 and older with overweight or obesity from the National Health and Nutrition Examination Surveys, 1999 to 2016 with a 2-year data-release cycle. The question of interest was "Has a doctor or other health professionals ever told you that you were overweight?" Adjusted biennial percentage ratio (abPR) of being notified was estimated. We observed a significant increasing trend of notification in adults with overweight [abPR = 1.04 (95% confidence interval: 1.03, 1.06), about 4% increase for every two-years] and obesity [1.01 (1.00, 1.02)]. The highest increase occurred in adults with overweight aged 20-34 [1.12 (1.08, 1.16)], however, young adults with overweight remained the group with the lowest percentage (24%, 2015-2016 survey) of notification compared to others in recent survey. Notification in adults with obesity demonstrated similar trends. In 2015-2016, among adults with obesity who visited HCPs last year, 80% of these aged 50-64 and 78% of these aged 65 and older were notified. More than 80% of adults with overweight or obesity visited HCPs at least once last year.

CONCLUSIONS

There was an improvement in informing patients of overweight/obesity status. However, less than a quarter of young adults with overweight were notified in recent surveys, compromising the opportunities of preventing overweight from becoming obesity in early adulthood.

Association of depression symptoms with receipt of healthcare provider advice on physical activity among US adults

BACKGROUND

Given the high burden and prevalence of depression, various guidelines underscore the role of healthcare providers in supplying advice on physical activity (PA) as a potential modifying factor influencing the incidence and severity of depressive symptoms in adults. We aimed to investigate the extent to which healthcare providers provide PA advice to adults with depressive symptoms in the US.

METHODS

Data on adults aged 20-64 years (n = 4971) in the National Health and Nutrition Examination Study between 2011 and 2016 were analysed. Depressive symptoms were assessed using the Patient Health Questionnaire and response options were categorised as "none or minimal", "mild", "moderate-severe". Receipt of PA advice from a healthcare provider was self-reported. We restricted our study sample to adults free from chronic diseases.

RESULTS

Higher odds of receiving advice to exercise were reported among adults with mild (OR = 1.7, 95% CI: 1.3-2.3) and moderate-severe depressive symptoms (OR = 1.7, 95% CI: 1.0-2.8). Furthermore, exercise advice was more commonly reported among adults who were overweight, obese, Hispanic, Asian, being insured with private insurance, with education higher than high school, and had access to a routine place for health care.

LIMITATIONS

Social and culutral aspects of overweight/obesity may prohibit generalizations. Cross sectional design does not allow for causal realtionships.

CONCLUSIONS

In the US, fewer than one in three adults experiencing symptoms of depression report having received exercise advice from a healthcare provider. Providing such advice may be a sustainable clinical strategy in reducing the incidence and severity of depression symptoms.

Weight History in Clinical Practice: The State of the Science and Future Directions

Eliciting a weight history can provide clinically important information to aid in treatment decision-making. This view is consistent with the life course perspective of obesity and the aim of patient-centered care, one of six domains of health care quality. However, thus far, the value and practicality of including a weight history in the clinical assessment and treatment of patients with obesity have not been systematically explored. For these reasons, the Clinical Committee of The Obesity Society established a task force to review and assess the available evidence to address five key questions. It is concluded that weight history is an essential component of the medical history for patients presenting with overweight or obesity, and there are strong and emerging data that demonstrate the importance of life stage, duration of exposure to obesity, maximum BMI, and group-based trajectory modeling in predicting risk for increased morbidity and mortality. Consideration of these and other patient-specific factors may improve risk stratification and clinical decision-making for screening, counseling, and management. Recommendations are provided for the key elements that should be included in a weight history, and several needs for future clinical research are outlined.

An analysis of directly observed weight communication processes between primary care practitioners and overweight patients

OBJECTIVE

To analyse weight-related communication prevalence and processes (content/context) between primary care practitioners (PCPs) and overweight patients within routine primary healthcare consultations.

METHODS

Consultations between 14 PCPs and 218 overweight patients (BMI ≥ 25 kg/m²) were video recorded. Weight communication was coded using the Roter Interaction Analysis System (RIAS) and the novel St Andrews Issue Response Analysis System (SAIRAS). Communication code frequencies were analysed.

RESULTS

Weight discussion occurred in 25% of consultations with overweight patients; 26% of these had weight-related consultation outcomes (e.g. weight-related counselling and referrals, stated weight-related intention from patients). Weight discussions were more likely to occur if PCPs provided space to patient attempts to discuss weight (p = 0.013). Longer weight discussions (p < 0.001) and contextualising weight as problematic when PCP/patient-initiated weight discussion (p < 0.001) were associated with weight-related consultation outcomes.

CONCLUSION

Weight was rarely discussed with overweight patients, however PCP space provision to patient weight-discussion initiation attempts increased weight discussion. When weight was discussed, increased time and/or contextualising weight as a problem increased the likelihood of weight-related consultation outcomes.

PRACTICAL IMPLICATION

PCP use of specific communication approaches when discussing, contextualising and responding to patient weight may facilitate weight-related discussion and consultation outcomes and could lead to more effective patient weight management.

Nutrition and physical activity counselling by general practitioners in Lithuania, 2000-2014

BACKGROUND

Primary health care plays a crucial role in providing recommendations on a healthy diet and physical activity to assist patients in weight management. The study aimed to evaluate health behaviour counselling provided by general practitioners (GPs) for adults with overweight and obesity in Lithuania between 2000 and 2014.

METHODS

Eight biennial postal surveys to independent nationally representative random samples of Lithuanians aged 20-64 were conducted. Response rates varied from 41.1 to 74%, with a decreasing trend over time. The data of 5867 participants who visited a GP at least once during the last year and had BMI of ≥25.0 kg/m² were analysed. Respondents were asked about GP advice on nutrition and physical activity and changes in their health behaviour during the last year.

RESULTS

The proportion of persons with overweight who reported GP advice on nutrition increased from 23.6% in 2000 to 37.5% in 2010 and advice on physical activity from 11.9 to 17.2% respectively; however, later both proportions decreased slightly. The likelihood of reporting was higher in respondents with higher BMI, more chronic conditions and frequent contact with a GP. Respondents who were living in cities, older and highly educated women were all more likely to report being advised on physical activity. Men and women who received advice from a GP more often reported changes in health behaviour as compared with non-advised individuals.

CONCLUSIONS

Despite increasing trends, the rate of GP advice on nutrition and physical activity reported by patients with overweight and obesity remains low in Lithuania. GP advice appears to have a significant impact on attempts by patients to change behaviour related to weight control. Therefore, there is an obvious need to make additional efforts to increase the frequency of GP counselling and to identify and address barriers to advising patients with overweight.

Health Care Providers' Advice on Lifestyle Modification in the US Population: Results from the NHANES 2011-2016

OBJECTIVE

Health care providers are encouraged to prescribe lifestyle modifications for preventing and managing obesity and associated chronic conditions. However, the pattern of lifestyle advice provision is unknown. We investigate the prevalence of advised lifestyle modification according to weight status and chronic conditions in a US nationally representative sample.

METHODS

Adults ages 20-64years (n = 11,467) from the National Health and Nutrition Examination Survey between 2011 and 2016 were analyzed, with weight status and chronic conditions (high blood pressure, high blood cholesterol, osteoarthritis, coronary heart disease, and type 2 diabetes mellitus). Lifestyle modification advice by health care providers included: increase physical activity/exercise, reduce dietary fat/calories, control/lose weight, and all of the above.

RESULTS

High blood pressure (32.7%) and cholesterol (29.3%) were highly prevalent compared with osteoarthritis (7.4%), type 2 diabetes (5.7%), and coronary heart disease (3.7%). Those with type 2 diabetes received considerably more frequent advice (56.5%; 95% confidence interval [CI], 52.4%-60.6%) than those with high blood pressure (31.4%; 95% CI, 29.3%-33.6%) and cholesterol (27.0%; 95% CI, 24.9%-29.3%). Prevalence of lifestyle advice exhibited substantial increases with graded body mass index and comorbidity (all P < .001). After adjusting for comorbid conditions, advice was more commonly reported among women, those overweight/obese, nonwhite, or insured. A remarkably low proportion of overweight (21.4; 95% CI, 18.7%-24.3%) and obese (44.2%; 95% CI, 41.0%-47.4%) adults free of chronic conditions reported receiving any lifestyle advice.

CONCLUSIONS

Prevalence of lifestyle modification advised by health care providers is generally low among US adults with chronic conditions, and worryingly low among those without chronic conditions, however overweight or obese. Prescribed lifestyle modification is a missing opportunity in implementing sustainable strategies to reduce chronic condition burden.

Rural-Urban Variation in Weight Loss Recommendations Among US Older Adults with Arthritis and Obesity

Purpose: Weight loss is advantageous for individuals with obesity and arthritis. Therefore, this study was conducted to determine if there are differences by rural-urban status among older adults with these conditions who reported being advised by a health care provider to lose weight for arthritis or to ameliorate arthritis symptoms. Methods: A cross-sectional analysis of 2011 Behavioral Risk Factor Surveillance System (BRFSS) data. Respondents reported if they had been diagnosed with arthritis and if they received a provider weight loss recommendation (WLR). The analytic sample was limited to older adults aged 60⁻79 living in the five states that administered the examined BRFSS arthritis module who had body mass index ≥ 30 kg/m² and reported having arthritis (n = 2920). The respondent's county of residence was linked to the corresponding county-level population density from the US Decennial Census to determine rural-urban status. A generalized linear model examined the association between receipt of a WLR and population density, controlling for demographics. Results: The sample was 83.6% white, 57.8% female, and 63.2% received a WLR. Respondents from more urban counties were more likely to receive a WLR (p value for trend <0.001). Additionally, older respondents, men, individuals with less than a high school education, and whites had a decreased likelihood of receiving a WLR. Conclusions: The analysis identified notable rural-urban differences with respondents in more urban counties being more likely to receive a WLR. Furthermore, there were differences in those who received a WLR by age, sex, and education. Reasons for these differences should be explored.

Underdocumentation of Obesity by Medical Residents Highlights Challenges to Effective Obesity Care

OBJECTIVE

The goal of this study was to determine attitudes and practices of physicians in training with respect to the evaluation and treatment of obesity.

METHODS

Resident-generated admission and discharge notes of all 1,765 general medicine hospital admissions during 4 nonconsecutive months were analyzed, and any references to weight, obesity, BMI, adiposity, and body fat were identified. The full general resident cohort was then surveyed for perceptions and behaviors related to obesity.

RESULTS

Obesity was considered a highly important medical issue by 98.5% of residents; 90% correctly identified a class II obesity Stunkard phenotype, and 80% accurately calculated a BMI given height and weight in metric units. Residents overestimated inpatient obesity prevalence (estimate = 75%; actual = 35%) and the rate of obesity recording in the hospital admission note (estimate = 94%; actual = 49.5%). A BMI or current weight in the admission note or discharge summary was reported in none of the 1,765 patient records, and only 6% of the patients with obesity had obesity noted in either the inpatient admission or discharge assessment or plan.

CONCLUSIONS

Though residents recognize obesity and its clinical implications, it is underreported in the assessment of inpatients. This low level of documenting obesity and its impact on clinical care planning underscores a missed opportunity to establish appropriate referrals and initiate treatment at a clinically opportune time.

Weight Loss Strategies for Treatment of Obesity: Lifestyle Management and Pharmacotherapy

Obesity is one of the most serious and prevalent non-communicable diseases of the twenty-first century. It is also a patient-centered condition in which affected individuals seek treatment through a variety of commercial, medical and surgical approaches. Considering obesity as a chronic medical disease state helps to frame the concept of using a three-stepped intensification of care approach to weight management. As a foundation, all patients should be counseled on evidence-based lifestyle approaches that include diet, physical activity and behavior change therapies. At the second tier, four new pharmacological agents, lorcaserin, phentermine/topiramate, naltrexone/bupropion and liraglutide have been approved since 2012 as adjuncts to lifestyle modification. The third step, bariatric surgery, has been demonstrated to be the most effective and long-term treatment for individuals with severe obesity or moderate obesity complicated by co-morbid conditions that is not responsive to non-surgical approaches. By using a medical model, clinicians can provide more proactive and effective treatments in assisting their patients with weight loss.

Impact of weight-related advice from healthcare professionals on body mass index of patients in the USA

OBJECTIVES

Healthcare professionals (HCPs) can help promote healthy eating and active living in patients. This study assessed the effects of weight-related advice from HCPs on change in body mass index (BMI) of patients in the USA.

STUDY DESIGN

A 1-year follow-up study of 20,002 adults who participated in a nationally representative survey between 2004 and 2008.

METHODS

Using the 2004-2008 Medical Expenditure Panel Survey data, 1-year BMI and weight status changes were compared between patients who did and did not report receiving advice on exercise or on restricted intake of fat and cholesterol from their HCPs.

RESULTS

Patients who received weight-related advice had a greater increase in BMI compared with those who did not receive weight-related advice. Stratified by the baseline weight status of patients (i.e. normal weight, overweight or obese), adverse direction of BMI change was only significantly associated with advice on exercise. Patients who received advice to exercise more were more likely to move to a higher weight status than remaining at the same weight status, compared with patients who did not receive advice to exercise more.

CONCLUSION

This study did not find that weight-related advice from HCPs had a positive impact on BMI loss in patients. On the contrary, patients who reported receiving weight-related advice from HCPs had worse weight outcomes 1 year later than patients who did not report receiving weight-related advice. Further research is warranted to elucidate the role of weight-related advice from HCPs on lifestyle change and obesity prevention and control.

Evidence of a gap in understanding obesity among physicians

Background

Experience suggests that some physicians view obesity as a purely lifestyle condition rather than a chronic metabolic disease. Physicians may not be aware of the role of biological factors in causing weight regain after an initial weight loss.

Methods

A questionnaire was administered at continuing medical education conferences, both primary care and obesity-specific. The questionnaire included items about biological and behavioral factors that predispose to weight regain and general items about treatment of obesity. The sample was separated into primary care physicians (PCPs) and physicians preparing for the obesity medicine (OMs) exam.

Results

Among all respondents, behavioral factors were given higher importance ratings, relative to biological factors in causing weight regain. Respondents rated behaviour modification as more effective, relative to medications or surgery to treat obesity. OMs gave higher importance ratings to biological factors, relative to PCPs. OMs also gave higher effectiveness ratings for medications and surgery, relative to PCPs. However, even OMs gave higher effectiveness ratings for behaviour modification, relative to medications or surgery. Respondents who reported a belief in the role of behavioral factors rated lifestyle modification as more effective. Respondents who reported a belief in both behavioral and biological factors rated medications as more effective.

Conclusions

Physicians rate biological factors as less important, relative to behavioral factors in causing weight regain. Physicians rate medications and surgery as less effective, relative to lifestyle modification alone. Belief in the importance of behavioral factors correlated with a higher effectiveness rating for lifestyle modification. A better understanding of the biological basis for weight regain may help to increase comfort with the use of biological treatments for obesity.

Treatment of Obesity in Primary Care

This article outlines some of the behavioral, pharmacologic, and surgical interventions available to primary care physicians (PCPs) to help their patients with weight management. Studies on lifestyle modification, commercial weight loss programs, and medical and surgical options are reviewed. Several clinical suggestions on obesity management that PCPs can take back and use immediately in office practice are offered.

The rising prevalence of obesity: part B-public health policy solutions

Obesity is likely to supersede tobacco as the biggest cause of premature death. England has some of the worst figures and trends in obesity compared with the rest of the Europe. Rising obesity prevalence is an international crisis that has the potential to overwhelm health care resources as well as creating enormous human suffering and social cost. This article outlines potential public health policy solutions to this crisis.

A brief intervention for weight control based on habit-formation theory delivered through primary care: results from a randomised controlled trial

BACKGROUND

Primary care is the 'first port of call' for weight control advice, creating a need for simple, effective interventions that can be delivered without specialist skills. Ten Top Tips (10TT) is a leaflet based on habit-formation theory that could fill this gap. The aim of the current study was to test the hypothesis that 10TT can achieve significantly greater weight loss over 3 months than 'usual care'.

METHODS

A two-arm, individually randomised, controlled trial in primary care. Adults with obesity were identified from 14 primary care providers across England. Patients were randomised to either 10TT or 'usual care' and followed up at 3, 6, 12, 18 and 24 months. The primary outcome was weight loss at 3 months, assessed by a health professional blinded to group allocation. Difference between arms was assessed using a mixed-effect linear model taking into account the health professionals delivering 10TT, and adjusted for baseline weight. Secondary outcomes included body mass index, waist circumference, the number achieving a 5% weight reduction, clinical markers for potential comorbidities, weight loss over 24 months and basic costs.

RESULTS

Five-hundred and thirty-seven participants were randomised to 10TT (n=267) or to 'usual care' (n=270). Data were available for 389 (72%) participants at 3 months and for 312 (58%) at 24 months. Participants receiving 10TT lost significantly more weight over 3 months than those receiving usual care (mean difference =-0.87kg; 95% confidence interval: -1.47 to -0.27; P=0.004). At 24 months, the 10TT group had maintained their weight loss, but the 'usual care' group had lost a similar amount. The basic cost of 10TT was low, that is, around £23 ($32) per participant.

CONCLUSIONS

The 10TT leaflet delivered through primary care is effective in the short-term and a low-cost option over the longer term. It is the first habit-based intervention to be used in a health service setting and offers a low-intensity alternative to 'usual care'.

Disparities in Who Receives Weight-Loss Advice From a Health Care Provider: Does Income Make a Difference?

Introduction

The US Preventive Services Task Force recommends that all patients be screened for obesity and, if needed, be provided weight-loss advice. However, the prevalence of such advice is low and varies by patient demographics. This study aimed to describe the determinants of receiving weight-loss advice among a sample with a high proportion of low-income, racial/ethnic minority individuals.

Methods

Data were collected from a telephone survey of 1,708 households in 2009 and 2010 in 5 cities in New Jersey. Analyses were limited to 1,109 overweight or obese adults. Multivariate logistic regression determined the association of participants’ characteristics with receiving weight-loss advice from their health care provider. Two models were used to determine differences by income and insurance status.

Results

Of all overweight or obese respondents, 35% reported receiving advice to lose weight. Receiving advice was significantly associated with income in multivariate analysis. Compared with those with an income at or below 100% of the federal poverty level (FPL), those within 200% to 399% of the FPL had 1.60 higher odds of receiving advice (P = .02), and those with an income of 400% or more of the FPL had 1.73 higher odds of receiving advice (P = .03). The strength of the association did not change after adjusting for health insurance.

Conclusion

Income is a significant predictor of whether or not overweight or obese adults receive weight-loss advice after adjustment for demographic variables, health status, and insurance status. Further work is needed to examine why disparities exist in who receives weight-loss advice. Health care providers should provide weight-loss advice to all patients, regardless of income.

Direct observation of weight-related communication in primary care: a systematic review

BACKGROUND

Primary care is ideally placed to play an effective role in patient weight management; however, patient weight is seldom discussed in this context. A synthesis of studies that directly observe weight discussion in primary care is required to more comprehensively understand and improve primary care weight-related communication.

OBJECTIVE

To systematically identify and examine primary care observational research that investigates weight-related communication and its relationship to patient weight outcomes.

METHODS

A systematic review of literature published up to August 2015, using seven electronic databases (including MEDLINE, Scopus and PsycINFO), was conducted using search terms such as overweight, obese and/or doctor-patient communication.

RESULTS

Twenty papers were included in the final review. Communication analysis focused predominantly on 'practitioner' use of specific patient-centred communication. Practitioner use of motivational interviewing was associated with improved patient weight-related outcomes, including patient weight loss and increased patient readiness to lose weight; however, few studies measured patient weight-related outcomes.

CONCLUSION

Studies directly observing weight-related communication in primary care are scarce and limited by a lack of focus on patient communication and patient weight-related outcomes. Future research should measure practitioner and patient communications during weight discussion and their impact on patient weight-related outcomes. This knowledge may inform the development of a communication intervention to assist practitioners to more effectively discuss weight with their overweight and/or obese patients.

Self-reported receipt of healthcare professional's weight management counselling is associated with self-reported weight management behaviours of type 2 diabetes mellitus patients

BACKGROUND

Weight loss has been shown to influence the health outcomes of type 2 diabetes patients. Providing weight management counselling to diabetes patients may help them adopt appropriate weight management behaviours to lose weight. This study determined the association between self-reported receipt of healthcare professional's weight management counselling and the weight management behaviours of type 2 diabetes patients.

METHODS

This cross-sectional study was conducted among 378 type 2 diabetes mellitus patients seeking care from two hospitals. Using a questionnaire, participants' weight management behaviours were assessed as well as receipt of healthcare professional's weight management counselling.

RESULTS

Half (51.3 %) of the participants reported receipt of healthcare professional's weight management counselling in the last 12 months. Half of the participants ever tried to lose weight. Fewer than half of the participants reported modifying their dietary habits (45.5 %) or engaging in exercise (48.7 %) to lose weight. Those who reported receipt of weight management counselling were more likely to report ever trying to lose weight (AOR 43.0, 95 % CI 23.0-81.6; p < 0.001), modifying their dietary habits (AOR 22.5, 95 % CI 13.0-39.19; p < 0.001), and engaging in exercise (AOR 13.0, 95 % CI 7.8-21.7; p < 0.001) to lose weight.

CONCLUSION

Participants engaged in varied weight management behaviours. Receipt of health care professionals' weight management counselling was associated to participants' reported participation in weight management behaviours. Weight management counselling from health care professionals may support the adoption of weight management behaviours in type 2 diabetes mellitus patients.

Treatment of obesity in 2015

Obesity is a major health priority in the United States, as well as globally. It is associated with multiple comorbidities and reduced life expectancy. Effective management of obesity involves producing an intervention plan tailored to the individual patient. Potential contributory factors to weight gain, including dietary habits, physical inactivity, associated medical conditions, and medications, should be identified and addressed. Lifestyle interventions comprising diet modification, physical activity, and behavior therapy are foundational to the management of obesity. Caloric restriction is the most important component in achieving weight loss through negative energy balance, whereas sustained physical activity is important in maintaining the weight loss. Adjunctive therapies in the form of pharmacotherapy and bariatric surgery are required in patients who do not achieve targeted weight loss and health goals with lifestyle interventions. Currently there are 3 drugs approved for long-term management of obesity, orlistat, phentermine/topiramate extended release, and lorcaserin, and there are 2 on the horizon, bupropion/naltrexone and liraglutide. Bariatric surgery is an effective strategy recognized to produce durable weight loss with amelioration of obesity-related comorbidities and should be considered a treatment option in eligible patients.

Women's Perceptions Regarding Obesity and Comorbidities and Provider Interaction

OBJECTIVE

To assess women's perceptions of current body mass index (BMI) category, evaluate their knowledge of medical and surgical conditions associated with obesity, and assess their previous exposure to counseling on obesity.

DESIGN

Questionnaire-based survey.

SETTING

Gynecology clinics in a large midwestern city.

PARTICIPANTS

Non-pregnant women age 18 to 65 years.

METHODS

Descriptive design with distribution of anonymous questionnaires pertaining to demographics, current medical conditions, perceived weight, medical conditions associated with obesity, surgical complications from obesity, and previous weight loss counseling. All data were analyzed using chi-squared tests, and statistical significance was set at a p value of <.05.

RESULTS

The majority of the sample (65%) was overweight or obese, and 44% of participants underestimated their BMI categories. The relationship of perceived versus actual BMI differed significantly by race (p < .001), income (p < .05), and education (p < .05); African American women and women with less education tended to underestimate their BMI categories. Increasing actual BMI was inversely correlated with the ability to identify obesity as a risk factor for medical conditions (p < .01). Only 43% of participants discussed their weight or related concerns with medical professionals.

CONCLUSION

A significant number of participants were unaware of their BMI status as well as the relationship between obesity and other comorbidities. Counseling and patient education efforts by health care providers are essential.

Multimorbidity and weight loss in obese primary care patients: longitudinal study based on electronic healthcare records

OBJECTIVE

To analyse the association between cardiovascular and mental comorbidities of obesity and weight loss registered in the electronic primary healthcare records.

DESIGN AND SETTING

Longitudinal study of a cohort of adult patients assigned to any of the public primary care centres in Aragon, Spain, during 2010 and 2011.

PARTICIPANTS

Adult obese patients for whom data on their weight were available for 2010 (n=62,901), and for both 2010 and 2011 (n=42,428).

OUTCOMES

Weight loss (yes/no) was calculated based on the weight difference between the first value registered in 2010 and the last value registered in 2011. Multivariate logistic regression models were adjusted for individuals' age, sex, total number of chronic comorbidities, type of obesity and length of time between both weight measurements.

RESULTS

According to the recorded clinical information, 9 of 10 obese patients showed at least one chronic comorbidity. After adjusting for covariates, weight loss seemed to be more likely among obese patients with a diagnosis of diabetes and/or dementia and less likely among those with hypertension, anxiety and/or substance use problems (p<0.05). The probability of weight loss was also significantly higher in male patients with more severe obesity and older age.

CONCLUSIONS

An increased probability of weight loss over 1 year was observed in older obese male patients, especially among those already manifesting high levels of obesity and severe comorbidities such as diabetes and/or dementia. Yet patients with certain psychological problems showed lower rates of weight reduction. Future research should clarify if these differences persist beyond potential selective weight documentation in primary care, to better understand the trends in weight reduction among obese patients and the underlying role of general practitioners regarding such trends.

The impact of physician weight discussion on weight loss in US adults

PROBLEM

The increasing prevalence of overweight and obesity in the United States and worldwide is at epidemic levels. Physicians may play a vital role in addressing this epidemic. We aimed to examine the association of a physician's discussion of patients’ weight status with self-reported weight loss. We hypothesized that physician discussion of patients’ being overweight is associated with increased weight loss in patients with overweight and obesity.

METHODS

Data analysis of participants (n = 5054) in the National Health and Nutritional Examination Survey (NHANES) in 2005-2008. The main outcome was rates of self-reported weight loss and the association with physicians’ discussion of their patients’ weight status.

RESULTS

Overweight and obese participants were significantly more likely to report a 5% weight loss in the past year if their doctor had told them they were overweight (adjusted OR (AOR) 1.88; 95% CI 1.45-2.44; AOR 1.79; 95% CI 1.30-2.46, respectively).

CONCLUSIONS

Physicians’ direct discussion of their patients’ weight status is associated with clinically significant patient weight loss and may be a targetable intervention. Further studies are needed to determine if increasing physician discussion of patients’ weight status leads to significant weight loss.

A randomised controlled trial of the effectiveness of self-weighing as a weight loss intervention

BACKGROUND

There is a need to find simple cost effective weight loss interventions that can be used in primary care. There is evidence that self-monitoring is an effective intervention for problem drinking and self-weighing might be an effective intervention for weight loss.

PURPOSE

To examine the efficacy of daily self-weighing as an intervention for weight loss.

METHODS

A randomised controlled trial of 183 obese adults, follow-up three months. The intervention group were given a set of weighing scales and instructed to weigh themselves daily and record their weight. Both groups received two weight loss consultations which were known to be ineffective.

RESULTS

92 participants were randomised to the intervention group and 91 to the control group. The intervention group lost 0.5 kg (95% CI 0.3 to 1.3 kg) more than the control group, but this was not significant. There was no evidence that self-weighing frequency was associated with more weight loss.

CONCLUSIONS

As an intervention for weight loss, instruction to weigh daily is ineffective. Unlike other studies, there was no evidence that greater frequency of self-weighing is associated with greater weight loss.

TRIAL REGISTRATION

ISRCTN05815264.

Dionne M, E. Cassin S, Wnuk S, Taube-Schiff M, Sockalingam S. Psychopathology in severely obese women from a Canadian bariatric setting

Purpose

– Evidence suggests high rates of psychiatric disorders in bariatric surgery candidates (e.g. Mitchell et al., 2012), although no rigorous studies have examined the prevalence in a Canadian sample. Improved understanding of the prevalence of psychopathology among female patients is an important area of study, as females comprise approximately 80 percent of surgical candidates (Martin et al., 2010; Padwal, 2005). The purpose of this paper is to assess the prevalence of Axis I disorders and associations with quality of life in a Canadian sample of female bariatric surgery candidates.

Design/methodology/approach

– Female patients (n=257) were assessed using a structured psychodiagnostic interview and completed a health-related quality of life questionnaire.

Findings

– Results indicated that 57.2 percent of patients met DSM-IV-TR criteria for a lifetime psychiatric disorder and 18.3 percent met criteria for a current psychiatric disorder. Major depressive disorder was the most common lifetime psychiatric disorder (35.0 percent) and binge eating disorder was the most prevalent current psychiatric disorder (6.6 percent). Patients scored significantly lower than Canadian population norms on all domains of the SF-36 (all p's<0.001). Patients with a current Axis I disorder also reported significantly worse functioning on four mental health domains and one physical health domain (p's<0.01) compared to patients without a current Axis I disorder.

Originality/value

– Results confirm high rates of psychiatric disorders in Canadian female bariatric surgery candidates and provide evidence for associated functional health impairment. Further study is needed to elucidate how pre-operative psychopathology may impact female patients’ post-operative outcomes.

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.

The impact of a health professional recommendation on weight loss attempts in overweight and obese British adults: a cross-sectional analysis

OBJECTIVES

To examine the effect that health professional (HP) advice to lose weight has on overweight and obese adults' motivation to lose weight and attempts to lose weight.

DESIGN

Cross-sectional survey.

SETTING

Great Britain.

PARTICIPANTS

810 overweight or obese (body mass index ≥25 kg/m(2)) adults.

MAIN OUTCOME MEASURES

Participants were asked if they had ever received HP advice to lose weight and reported their desire to weigh less (ideal weight ≤95% of current weight) and whether they were attempting to lose weight.

RESULTS

Only 17% of overweight and 42% of obese respondents recalled ever having received HP advice to lose weight. HP advice was associated with wanting to weigh less (89% vs 61% among those not receiving advice) and attempting to lose weight (68% vs 37%). In multivariable analyses, HP advice to lose weight was associated with increased odds of wanting to weigh less (OR=3.71, 95% CI 2.10 to 6.55) and attempting to lose weight (OR=3.53, 95% CI 2.44 to 5.10) independent of demographic characteristics and weight status.

CONCLUSIONS

HP advice to lose weight appears to increase motivation to lose weight and weight loss behaviour, but only a minority of overweight or obese adults receive such advice. Better training for HPs in delivering brief weight counselling could offer an opportunity to improve obese patients' motivation to lose weight.

Weight loss strategies for treatment of obesity

Obesity is one of the most serious and prevalent non-communicable diseases of the 21st century. It is also a patient-centered condition in which affected individuals seek treatment through a variety of commercial, medical and surgical approaches. Considering obesity as a chronic medical disease state helps to frame the concept of using a three-stepped intensification of care approach to weight management. As a foundation, all patients should be counseled on evidence-based lifestyle approaches that include diet, physical activity and behavior change therapies. At the second tier, two new pharmacological agents, phentermine-topiramate and lorcaserin, were approved in 2012 as adjuncts to lifestyle modification. The third step, bariatric surgery, has been demonstrated to be the most effective and long-term treatment for individuals with severe obesity or moderate obesity complicated by comorbid conditions that is not responsive to non-surgical approaches. By using a medical model, clinicians can provide more proactive and effective treatments in assisting their patients with weight loss.

Preventive counseling for chronic disease: missed opportunities in a community mental health center

BACKGROUND

The tremendous burden of cardiovascular risk among persons with serious mental illness underscores a critical need for prevention. Counseling by primary care clinicians increases patient smoking cessation, physical activity, and the consumption of fruits and vegetables. The extent to which community mental health clinicians counsel about cardiovascular risk factors has not been reported.

METHODS

This cross-sectional study examines the rates of counseling about cardiovascular risk factors by mental health providers at an urban community mental health center (n = 154). Logistic regression analyses identified clinician characteristics associated with counseling more than 50% of clients about diet, exercise, and smoking.

RESULTS

72% of clinical staff members responded to the survey, for a sample of 154 mental health clinicians; 26.6% of the clinicians counseled more than half of their clients annually about all three cardiovascular disease (CVD) risk factors. Logistic regression showed that mental health providers who counseled clients about CVD risk factors were less likely to be obese, and were more likely to have received formal training about how to counsel clients about CVD risk.

DISCUSSION

This is the first study to examine the routine clinical practice of community mental health clinicians in addressing CVD risk at an urban community mental health center. Both training mental health clinicians about CVD risk and also support for improving clinician health status may improve the preventive care provided to clients at community mental health centers.

Primary care providers' communication with patients during weight counseling: a focus group study

OBJECTIVE

Primary care providers (PCPs) are encouraged to counsel their obese patients about weight loss. We used focus groups to explore how PCPs communicate with patients about weight management.

METHODS

During the summer of 2010, we conducted five focus groups of community-based PCPs who had patients enrolled in a practice-based, randomized controlled weight loss trial in Maryland. Focus groups were audio-recorded and transcribed verbatim. Two investigators independently coded transcripts for thematic content using editing style analysis.

RESULTS

Twenty-six PCPs from six different practices participated. Mean years in practice were 16.4 (SD 11.7) and 77% practiced internal medicine. We identified three communication-based themes about weight loss counseling: (1) motivating patients to lose weight, (2) partnering with the patient to achieve weight loss, and (3) handling challenges that arise during weight counseling.

CONCLUSION

PCPs use a variety of strategies to communicate with their patients about weight loss. Some PCPs already use patient-centered approaches to communicate with their patients about weight loss, suggesting that future weight counseling interventions should be tailored to build upon this strength.

PRACTICE IMPLICATIONS

PCPs' weight loss counseling may be improved by using techniques with demonstrated behavior change effectiveness such as the 5A's or motivational interviewing.

Secular trends in the diagnosis and treatment of obesity among US adults in the primary care setting

Excess weight afflicts the majority of the US adult population. Research suggests that the role of primary care physicians in reducing overweight and obesity is essential; moreover, little is known about self-care of obesity. This report assessed the secular trends in the care of overweight and investigated the secular association between obesity with care of overweight in primary care and self-care of overweight. Cross-sectional evaluation of the National Health and Nutrition Examination Survey (NHANES) III (1988-1994) and the Continuous NHANES (1999-2008) was employed; the total sample comprised 31,039 nonpregnant adults aged 20-90 years. The relationship between diagnosed overweight, and directed weight loss with time and obesity was assessed. Despite the combined secular increase in the prevalence of overweight and obesity (BMI >25.0 kg/m(2)) between 1994 and 2008 (56.1-69.1%), there was no secular change in the odds of being diagnosed overweight by a physician when adjusted for covariates; however, overweight and obese individuals were 40 and 42% less likely to self-diagnose as overweight, and 34 and 41% less likely to self-direct weight loss in 2008 compared to 1994, respectively. Physicians were also significantly less likely to direct weight loss for overweight and obese adults with weight-related comorbidities across time (P < 0.05). Thus, the surveillance of secular trends reveals that the likelihood of physician- and self-care of overweight decreased between 1994 and 2008 and further highlights the deficiencies in the management of excess weight.

The reporting of previous lifestyle counseling by persons at high risk of Type 2 diabetes

OBJECTIVE

To assess (i) whether the reporting of counseling previously received is associated with high-risk individuals' agreement to participate in lifestyle intervention, (ii) whether the reporting of previous counseling differed within such a high-risk group, and (iii) the associations between lifestyles and previous lifestyle counseling.

METHODS

Cross-sectional data were drawn from 10149 adults at high risk of Type 2 diabetes, who were participating in a Finnish national diabetes prevention project (FIN-D2D). Bivariate analysis and multivariate logistic regression were used.

RESULTS

In relation to the reporting of previous counseling, no difference was found between persons who had agreed and persons who had not agreed to participate in the lifestyle intervention. Persons who were more educated or who had dyslipidemia or diabetes were more likely than the others to report previous counseling. A generally healthy lifestyle, or certain health behaviors (being a non-smoker or eating large amounts of fruit and vegetables) may make the reporting of previous counseling more likely.

CONCLUSION

The results raise questions about the amount and quality of the previously received lifestyle counseling.

PRACTICE IMPLICATIONS

There is a need for sustainable lifestyle counseling structures, within vigorously implemented diabetes prevention projects, if long-lasting lifestyle changes are to be achieved.

Addressing obesity in pregnancy: what do obstetric providers recommend?

OBJECTIVE

Maternal obesity is associated with adverse pregnancy outcomes. To improve outcomes, obstetric providers must effectively evaluate and manage their obese pregnant patients. We sought to determine the knowledge, attitudes, and practice patterns of obstetric providers regarding obesity in pregnancy.

METHODS

In 2007-2008, we surveyed 58 practicing obstetricians, nurse practitioners, and certified nurse-midwives at a multispecialty practice in Massachusetts. We administered a 26-item questionnaire that included provider self-reported weight, sociodemographic characteristics, knowledge, attitudes, and management practices. We created an 8-point score for adherence to 8 practices recommended by the American College of Obstetricians and Gynecologists (ACOG) for the management of obese pregnant women.

RESULTS

Among the respondents, 37% did not correctly report the minimum body mass index (BMI) for diagnosing obesity, and most reported advising gestational weight gains that were discordant with 1990 Institute of Medicine (IOM) guidelines, especially for obese women (71%). The majority of respondents almost always recommended a range of weight gain (74%), advised regular physical activity (74%), or discussed diet (64%) with obese mothers, but few routinely ordered glucose tolerance testing during the first trimester (26%), planned anesthesia referrals (3%), or referred patients to a nutritionist (14%). Mean guideline adherence score was 3.4 (SD 1.9, range 0-8). Provider confidence (beta = 1.0, p = 0.05) and body satisfaction (beta = 1.5, p = 0.02) were independent predictors of higher guideline adherence scores.

CONCLUSIONS

Few obstetric providers were fully compliant with clinical practice recommendations, defined obesity correctly, or recommended weight gains concordant with IOM guidelines. Provider personal factors were the strongest correlates of self-reported management practices. Our findings suggest a need for more education around BMI definitions and weight gain guidelines, along with strategies to address provider personal factors, such as confidence and body satisfaction, that may be important predictors of adherence to recommendations for managing obese pregnant women.

Disparities in counseling for lifestyle modification among obese adults: insights from the Dallas Heart Study

Clinician counseling is a catalyst for lifestyle modification in obesity. Unfortunately, clinicians do not appropriately counsel all obese patients about lifestyle modification. The extent of disparities in clinician counseling is not well understood. Obese participants (BMI ≥30 kg/m(2), N = 2097) in the Dallas Heart Study (DHS), a probability-based sample of Dallas County residents ages 18-65, were surveyed regarding health-care utilization and lifestyle counseling over the year prior to DHS enrollment. Health-care utilization and counseling were compared between obese participants across three categories based on the presence of 0, 1, or 2+ of the following cardiovascular (CV) risk factors: hypertension, hypercholesterolemia, or diabetes. Logistic regression modeling was used to determine likelihood of counseling in those with 0 vs. 1+ CV risk factors, stratified by race, adjusting for age, sex, insurance status, and education. Among obese subjects who sought medical care, those with 0 CV risk factors, compared to those with 1 or 2+ CV risk factors, were less likely to report counseling about losing weight (41% vs. 67% vs. 87%, P trend <0.001), dietary changes (44% vs. 71% vs. 85%, P trend <0.001), and physical activity (46% vs. 71% vs. 86%, P trend <0.001). Blacks and Hispanics without CV risk factors had a lower odds of receiving counseling than whites without risk factors on weight loss (adjusted odds ratio (OR), 95% confidence interval (CI) for nonwhites 0.19, [0.13-0.28], whites 0.48, [0.26-0.87]); dietary changes (nonwhites 0.19, [0.13-0.27], whites 0.37, [0.21-0.64]); and physical activity (nonwhites 0.22, [0.16-0.32], whites 0.32, [0.18-0.57]). Lifestyle counseling rates by clinicians are suboptimal among obese patients without CV risk factors, especially blacks and Hispanics. Systematic education about and application of lifestyle interventions could capitalize on opportunities for primary CV risk prevention.

Obesity is more strongly associated with inappropriate eating behaviors than with mental health in older adults receiving congregate meals

This study explored the relationships of inappropriate eating behaviors and mental health with obesity in congregate meal participants in Georgia (N = 120, mean age = 75 years, 75% female, 43% African American). Inappropriate eating behaviors were evaluated with the Three-Factor Eating Questionnaire (18 questions); mental health was assessed with the Depression Anxiety Stress Scale (21 questions); history of depression was assessed with the Behavioral Risk Factor Surveillance Survey; and height and weight were measured to calculate body mass index (BMI) and obesity (52% ≥ 30 kg/m(2)). In bivariate analyses, obesity was associated with cognitive restraint (rho = 0.49, p < 0.0001), uncontrolled eating (rho = 0.22; p < 0.01), emotional eating (rho = 0.32, p < 0.001), and stress (rho = 0.18, p < 0.05), but not with depression or anxiety. In multivariate regression analyses including all six eating behavior and mental health indices, only cognitive restraint and emotional eating were consistently associated with obesity (p < 0.05) when controlled for potential confounders (demographics, food insecurity, and chronic health conditions). Thus, mental health symptoms and inappropriate eating behaviors, particularly cognitive restraint and emotional eating, may be important targets for future research and intervention. Additional research is needed to better understand how cognitive restraint and emotional eating contribute to obesity in this population so that interdisciplinary research and health care teams can appropriately prevent and manage obesity in congregate meal participants.

Medical and behavioral evaluation of patients with obesity

Obesity may be the most significant medical problem that health care providers will face over the coming decades. Physicians must aggressively address this chronic disease, providing both preventive and therapeutic care. Since this topic has not been traditionally taught in medical school or residency training, physicians and other health providers will need to acquire the knowledge, skills, and attitudes necessary to be effective obesity care providers. Performing a detailed initial assessment, including an obesity focused history, physical examination, and selected laboratory and diagnostic tests is fundamental to the process of care.

Health professional advice for smoking and weight in adults with and without diabetes: findings from BRFSS

Health risk behaviors including smoking and weight-gain can cause and exacerbate chronic diseases like diabetes. Brief provider advice is an effective intervention to reduce risk from these behaviors. However, behavioral advice is provided more often to those who already have a chronic illness when compared with those who are at risk. The purpose of this study is to determine whether the frequency of provider advice for smoking cessation and weight loss varies between overweight or obese smokers with and without diabetes. BRFSS data from a subset of overweight and obese smokers with (n = 848) and without (n = 6,279) diabetes were analyzed to determine differences in reported provider advice. Overweight and obese smokers with diabetes reported receiving more advice for both weight (46.4% vs. 23.4%, P < 0.001) and smoking (84.5% vs. 72.8%, P < 0.001) compared to those without diabetes. Advice for smoking cessation was reported two to three times more often than advice for weight. Nearly a quarter of those with diabetes and almost half of those without reported no receipt of advice about weight. Results indicate that providers are not adequately addressing overweight and obesity in patients with and at risk for diabetes.

Factors affecting weight counseling attitudes and behaviors among U.S. medical students

PURPOSE

To identify the factors associated with perceived relevance and reported frequency of weight counseling among medical students.

METHOD

The authors surveyed all medical students in the Class of 2003 at 16 U.S. medical schools during first-year orientation (1999), orientation to wards (2000-2001), and fourth year (2002-2003).

RESULTS

Across the three time points, response rates were, respectively, 89% (1,846/2,080), 82% (1,630/1,982), and 77% (1,469/1,901); a total of 2,316 medical students participated. More than half of the students felt that weight counseling was highly relevant to their intended practice (respectively, 63% [1,149/1,812], 70% [1,050/1,509], and 54% [717/1,329]). Among fourth-year students, 25% (350/1,393) reported that they "usually-always" provided weight counseling to general medicine patients. Perceived relevance peaked at orientation to wards (odds ratio [OR]=1.88), then declined to initial levels.Greater school support for health promotion was positively associated with high counseling frequency (OR=1.06). Students interested in non-primary-care specialties were less likely than others to consider weight counseling highly relevant (OR=0.59) or, in their fourth year, to provide it to patients (OR=0.50). Finally, higher personal fruit/vegetable consumption and confidence that this intake would increase were positively associated with high perceived relevance (both OR=1.07) and frequency of weight counseling (OR=1.09 and 1.16, respectively).

CONCLUSIONS

The majority of medical students consider weight counseling relevant to their intended careers. Promoting healthy personal behaviors and encouraging acquisition of skills in weight management across all specialties would likely improve clinical practice.

Lifestyle behaviors and physician advice for change among overweight and obese adults with prediabetes and diabetes in the United States, 2006

INTRODUCTION

The objective of this study was to examine the lifestyle behaviors of overweight and obese people with prediabetes or diabetes and to determine whether an association exists between reported behaviors and physician advice for behavior change.

METHODS

This investigation included overweight and obese people (body mass index ≥25.0 kg/m(2)) with prediabetes and diabetes aged 40 years or older identified from the 2006 National Health Interview Survey. Respondents reported attempts to control or lose weight, reduce the amount of fat or calories in their diet, and increase physical activity. Respondents also reported receipt of a physician recommendation for behavioral change in 1 or more of these areas. Data analysis included use of logistic regression stratified by sex and prediabetes/diabetes status to model odds of behavior by physician advice.

RESULTS

Most people reported trying to control or lose weight (prediabetes, 82%; diabetes, 75%). Fewer identified efforts to reduce the amount of fat or calories in their diet (prediabetes, 62%; diabetes, 71%) or increase physical activity (prediabetes, 53%; diabetes, 57%). Approximately one-third reported not receiving physician advice for each of these behavior changes. In logistic regression, physician advice for reducing the amount of fat or calories in the diet and increasing physical activity was generally associated with the reported corresponding behavior.

CONCLUSION

Many respondents reported trying to control or lose weight, but fewer reported actually reducing fat or calories in their diet or increasing physical activity. Physician advice may influence attempts at behavior change among overweight and obese patients with prediabetes and diabetes.

The time burden of overweight and obesity in primary care

Background

Overweight and obesity are associated with many conditions treated in primary care. Our objectives were: 1) to determine the frequency of weight-related conditions in a national sample of outpatient visits in the United States; 2) to establish the percentage of diagnosis codes and visit codes attributable to overweight and obesity; and 3) to estimate time spent to address these conditions, including time attributable to overweight and obesity itself.

Methods

We analyzed primary care visits from the 2005 and 2006 National Ambulatory Medical Care Survey (NAMCS) in the United States. Weight-related conditions included diabetes, hypertension, hyperlipidemia, obesity, cardiovascular disease, osteoarthritis, and low back pain. We used multivariable logistic regression to estimate an odds ratio for each weight-related condition, which we then converted to an attributable fraction (AF). The AF represents the percentage of diagnosis codes and visit codes attributable to excess weight for that condition. We then divided total visit time among all diagnoses and clinical items addressed at the primary care visit. Finally, to calculate the time attributable to overweight and obesity, we multiplied the AFs by the time spent on each weight-related condition.

Results

The total number of clinical items (diagnoses + medications + tests + counseling) was estimated to be 7.6 per patient, of which 2.2 were weight-related. Of a total visit time of 21.77 minutes, time spent addressing weight-related conditions was 5.65 minutes (30%), including 1.75 minutes (8.0%) attributable to overweight and obesity.

Conclusions

Approximately 8% of time from primary care visits is attributable to overweight and obesity. This estimate is conservative because the NAMCS only allows for coding of three diagnoses addressed per visit. Estimates of the time burden of overweight and obesity provide data to prioritize weight management for prevention and treatment.

Development of an online diabetes prevention lifestyle intervention coaching protocol for use in primary care practice

PURPOSE

The translation of an evidence-based lifestyle intervention to an online delivery format has the potential to provide an effective treatment option for obesity in primary care practice. Research is needed, however, to standardize e-counseling procedures to promote the training of health coaches and the dissemination to primary care settings. This article describes the development of an online lifestyle intervention coaching protocol adapted from the Diabetes Prevention Program lifestyle intervention curriculum.

CONCLUSIONS

The delivery of patient counseling via the Internet may enable the dissemination of high-quality lifestyle advice to prevent diabetes in patients whose schedules or geographic constraints prohibit their participation in in-person counseling sessions.

Project HEAL: peer education leads to weight loss in Harlem

BACKGROUND

Obesity and diabetes are epidemic in the predominantly minority Harlem community. To address them, a coalition of community and academic leaders tested the effectiveness of a peer-led weight loss course.

METHODS

The coalition developed Project HEAL: Healthy Eating, Active Lifestyles through extensive collaboration with community members and experts in nutrition, exercise, and peer education. We piloted the course in a local church and assessed its impact through pre and post course weights, self-reported behaviors and quality of life.

RESULTS

Twenty-six overweight and obese African American adults lost a mean of 4.4 pounds at 10 weeks, 8.4 pounds at 22 weeks, and 9.8 pounds at 1 year. Participants reported decreased fat consumption and sedentary hours, and improved health related quality of life.

CONCLUSIONS

A peer-led, community-based course can lead to weight loss and behavior change. The minority communities most affected by obesity and diabetes may benefit from this low-cost, culturally appropriate intervention.