Barriers to obesity management: a pilot study of primary care clinicians

Self-Perceived Nutritional Competency of Primary Healthcare Physicians in Qassim, Saudi Arabia

INTRODUCTION

Overnutrition plays a vital role in the development of a spectrum of non-communicable diseases. Diet-related disorders have a huge impact on personal health as well as the country's economy for the management of such disorders. The study aims to assess the primary healthcare physicians' nutrition competency, which will be beneficial for evaluating the current situation and future strategies, training, nutrition care, and disease prevention.

METHODOLOGY

Among 147 primary healthcare physicians by simple random sampling from four cities and two rural areas of Qassim, Saudi Arabia, from December 2022 to December 2023 using a validated (NUTCOMP) tool. Data were entered, cleaned, and analyzed with SPSS software version 21.0 (IBM Corp., Armonk, NY). Informed consent was obtained from all study participants. Chi-square and ANOVA tests were applied to draw the significant differences.

RESULTS

A total of 147 participants enrolled in this study, and the mean age and standard deviation (SD) of the study population were 34.38 ± 6.57. More than half of the physicians (n = 76, 51.7%) continued education on nutrition. Significant mean differences were observed between some and focused nutrition content received physicians versus no nutrition content received physicians concerning nutrition skill, communication, and nutrition attitude consecutively (P < 0.0001, P < 0.0001, and P < 0.0001). The mean nutrition knowledge, skill, communication, attitude score, and SD of PHCC physicians were 26.91 ± 5.42 (maximum 35), 31.19 ± 6.18 (maximum 40), 36.73 ± 7.48 (maximum 45), and 34.74 ± 6.23 (maximum 40), respectively.

CONCLUSIONS

Our study results show primary healthcare physicians perceive themselves to have good nutritional competency.

What advice do general practitioners give to people living with obesity to lose weight? A qualitative content analysis of recorded interactions

BACKGROUND

Guidelines recommend general practitioners (GPs) take every opportunity to talk to people living with obesity about their weight, and evidence shows even very brief advice is associated with weight loss. However, little is known about what GPs say when giving brief behavioural advice, and if it reflects evidence-based recommendations for people living with obesity. To understand what behavioural advice GPs give, we categorized the content and delivery of GPs' advice during brief interventions.

METHODS

Qualitative content analysis was applied to 159 audio recordings of consultations from the Brief Interventions for Weight Loss (BWeL) trial, where GPs gave brief weight-loss advice to patients with a body mass index ≥30 kg/m2 (or ≥25 kg/m2 if Asian) in 137 UK surgeries. Similar content was grouped into descriptive clusters.

RESULTS

The results comprised 4 clusters, illuminating different aspects of the advice given: (i) Content of diet and physical activity advice, showing this was highly varied; (ii) Content of "implementation tips" given to support changes, e.g. using smaller plates; (iii) Content of signposting support, either towards further clinician support, or other resources, e.g. information booklets; (iv) Style of advice delivery, showing GPs rarely gave personalized advice, or reasons for their advice.

CONCLUSIONS AND IMPLICATIONS

Weight-loss advice from GPs to patients with obesity rarely included effective methods, mostly communicating a general "eat less, do more" approach. Advice was mostly generic, and rarely tailored to patients' existing knowledge and behaviours. Effectiveness of brief weight-loss advice could be improved if GPs were given clearer guidance on evidence-based recommendations.

Treatment of overweight and obesity in general practice: a cluster randomised trial

Overweight and obesity are among the most serious health problems of our time. A majority of patients with overweight and obesity will first get in touch with health services through primary care. This makes it crucial to develop strategies to enable physicians in primary care to help and treat patients with overweight and obesity. The physicians tend to avoid this subject. The main reason is reported to be lack of knowledge and education, and that they have nothing concrete to offer their patients. We wanted to examine if a simple method with specific measures could be used in Norwegian general practice and achieve meaningful weight loss. 23 physicians and 210 patients participated in the study. The physicians who participated were cluster randomised into either control group or intervention group. The physicians in the control group were told to follow their usual approach, while the physicians in the intervention group followed a fixed plan with specific diets given orally and in writing to the patients. The inclusion criteria for both groups were: body mass index (BMI)>30 kg/m2, or BMI>25 kg/m2 with at least one weight-related condition. Weight was measured at the start, then after 1 year and finally after 2 years in both groups. We found no significant weight loss in the control group. In the intervention group, there was a weight loss of at least 10% by 25.5% after the first year and 24.2% after the entire observation period. 53.5% of the patients lost at least 5% of their weight in the first year and nearly 45% after the entire observation period. We conclude that a simple tool with a specific diet and activity plan is feasible in general practice and may produce significant weight loss. Trial registration number: NCT03000062.

The (cost) effectiveness of a very low-energy diet intervention with the use of eHealth in patients with type 2 diabetes and obesity: study protocol for a randomised controlled non-inferiority trial (E-diet trial)

BACKGROUND

Despite preventive measures, the number of people with type 2 diabetes and obesity is increasing. Obesity increases morbidity and mortality in people with type 2 diabetes, making weight loss a cornerstone of treatment. We previously developed a very low energy diet (VLED) intervention that effectively reduced weight in people with type 2 diabetes in the long term. However, this intervention requires considerable time and manpower, which reduces the number of people who can benefit from it. eHealth offers more efficient solutions but has proven to be less effective than face-to-face interventions. Therefore, we want to investigate whether a blended version of our VLED intervention (in which face-to-face contact is partly replaced by an eHealth (mobile) application (E-VLED)) would be more cost-effective than the current face-to-face intervention.

METHODS

We will conduct a randomised, controlled trial with non-inferiority design in patients with type 2 diabetes and obesity (BMI > 30 kg/m2), aged 18-75 years. The control group will receive the usual care VLED intervention, while the intervention group will receive the E-VLED intervention for 1 year, where face-to-face contact will be partly replaced by an eHealth (mobile) application. The main study endpoint is the difference in weight (% change) between the control and intervention group after 1 year, plus the difference between the total costs (euro) of the treatment in the control and intervention groups. The secondary aims are to investigate the effectiveness of the E-VLED diet intervention regarding cardiovascular risk factors, quality of life, patient satisfaction, compliance, and to study whether there is a difference in effectiveness in pre-specified subgroups. General linear models for repeated measurements will be applied for the statistical analysis of the data.

DISCUSSION

We hypothesise that the E-VLED intervention will be equally effective compared to the usual care VLED but lower in costs due to less time invested by the dietician. This will enable to help more people with type 2 diabetes and obesity to effectively lose weight and improve their health-related quality of life.

TRIAL REGISTRATION

Netherlands Trial Register, NL7832, registered on 26 June 2019.

Healthy lifestyle counseling, and barriers perceived by general practitioners in Poland

Introduction

The aim of the study was to determine the influence of the personal factors, such as body mass index (BMI), of general practitioners (GPs), and their counseling on weight management, healthy lifestyle, and their perceived barriers.

Materials and methods

The cross-sectional study was conducted from January 2020 to December 2021 among 161 GPs in the city of Lodz.

Results

Only 3.7% of physicians always advised their patients on diet and physical activity (p < 0.05). Most of the GPs (54%) provide counseling occasionally. GPs gave general advice more often to patients with chronic diseases than to patients who did not. The study showed that the chance of providing advice on eating habits or physical activity was significantly higher for the GPs who practiced physical activity (OR = 2.64; 95%Cl: 1.01-6.91, p < 0.05) and measured patient weight, height, and BMI (OR = 4.86; 95%Cl: 1.86-12.67, p < 0.001). GPs who were overweight (OR = 3.55; 95%Cl: 1.49-8.41, p < 0.01) and measured patient weight, height, and BMI (OR = 3.61; 95%Cl: 1.58-8.25, p < 0.01) were more likely to advise on nutrition or physical activity to "healthy" patients. Doctors who measured patient weight, height, and BMI advised patients with chronic diseases (OR = 6.45; 95%Cl: 2.54-16.34, p < 0.001). Over 40% of GPs believe that they are not effective in counseling. Lack of time turned out to be the main barrier to counseling for 73.3% of GPs, which was associated with heavy workload (>100 visits per week).

Conclusion

As many GPs doubt their effectiveness, it is recommended that GPs attend more training activities regarding counseling. In addition, organizational changes are needed to reduce patient numbers, and financial incentives are needed to improve counseling and patient measurement.

Physical Activity Counseling and Documentation by Pediatric Residents in Primary Care: Before and After Introduction of the FITT Principle

Physician training on physical activity (PA) counseling in patient care is highly variable. The objective of this study was to improve PA counseling by pediatric residents through introduction of the four components of PA, called the FITT principle (frequency, intensity, time, type). Pediatric residents (n=30) received lectures, curriculum content, and an electronic smart-phrase addressing PA in obesity, including the FITT principle. Surveys assessed resident attitudes, and chart reviews (n = 423 over 16 months) identified evidence of PA counseling including FITT principle components preintervention and postintervention. Survey results showed positive attitudes and confidence regarding primary care provider roles in counseling on PA, with no differences postintervention. Chart reviews demonstrated increased documentation on PA frequency postintervention (pre 31.9% vs post 50.9%, P=.00006), but no significant changes in intensity, time or type. In conclusion, a focused PA curriculum promoted PA counseling by pediatric residents, with increased documentation of one component of the FITT principle.

Development of a telehealth obesity OSCE and reliable checklist for assessment of resident physicians: a pilot study

BACKGROUND

Obesity is a major public health problem, yet residents undergo little formal training and assessment in obesity-related care. Given the recent growth of telehealth, physicians must further learn to apply these skills using a virtual platform. Therefore, we aimed to develop an objective structured clinical examination (OSCE) with reliable checklists to assess resident ability to take a patient-centered obesity-focused history that was feasible over telehealth based on published obesity competencies for medical education.

METHODS

We developed a 15-minute telehealth OSCE to simulate an obesity-related encounter for residents modified from a script used to assess medical student obesity competencies. We designed three checklists to assess resident skills in history taking, communication and professionalism during the obesity-related encounter. Resident performance was assessed as the percentage of obesity-related history taking questions asked during the encounter and as the mean communication and professionalism scores on a scale of 1 through 5 with 1 representing unacceptable/offensive behavior and 5 representing excellent skills. Encounters and assessments were completed by two commissioned actors (standardized patients) and 26 internal medicine residents over a secure online platform. We assessed the reliability of each checklist by calculating the percent agreement between standardized patients and the kappa (κ) statistic on each checklist overall and by each checklist item.

RESULTS

Overall agreement between standardized patients on the history taking, communication and professionalism checklists were 83.2% (κ = 0.63), 99.5% (κ = 0.72) and 97.8% (κ =0.44), respectively. On average, residents asked 64.8% of questions on the history taking checklist and scored 3.8 and 3.9 out of 5 on the communication and professionalism checklists, respectively.

CONCLUSIONS

Results from this pilot study suggest that our telehealth obesity OSCE and checklists are moderately reliable for assessing key obesity competencies among residents on a virtual platform. Integrating obesity OSCEs and other educational interventions into residency curricula are needed to improve resident ability to take an obesity-focused history.

Primary care physicians’ knowledge and attitudes about obesity, adherence to treatment guidelines and association with confidence to treat obesity: a Swedish survey study

Background

Obesity is a chronic disease with increasing prevalence. We aimed to explore primary care physicians’ knowledge and attitudes about obesity and how knowledge and attitudes are associated with confidence and adherence to obesity guidelines and barriers to obesity treatment.

Methods

A questionnaire survey was sent by e-mail to 1642 primary care physicians in four regions in Sweden. The survey focused on the physicians’ knowledge, attitudes towards obesity, confidence in obesity management, adherence to obesity guidelines and barriers to optimal care. We created different statistical indices for knowledge, attitudes and adherence. To analyse the correlation between these indices, we used linear regression analyses.

Results

Replies from 235 primary care physicians yielded a response rate of 14.3%. Most physicians answered correctly that obesity is a disease (91%), that obesity regulation sits in the hypothalamus (70%) and that obesity is due to disorders of appetite regulation (69%). However, 44% of the physicians thought that the most effective weight reduction method for severe obesity was lifestyle changes; 47% believed that obesity is due to lack of self-control, 14% mentioned lack of motivation and 22% stated laziness. Although 97% believed that physicians can help individuals with obesity and 56% suggested that obesity treatment should be prioritised, 87% of the physicians expressed that losing weight is the patients’ responsibility. There was a positive association between higher knowledge and better adherence to obesity guidelines (B = 0.07, CI 0.02–0.12, p-value = 0.005) and feeling confident to suggest medication (p < 0.001) or bariatric surgery (p = 0.002). While 99% of the physicians felt confident to discuss lifestyle changes, 67% and 81% were confident to suggest medication or bariatric surgery, respectively. Respondents perceived that the greatest barrier in obesity management was lack of time (69%) and resources (49%).

Conclusion

There was a positive association between Swedish primary care physicians’ knowledge and adherence to obesity guidelines and being more confident to suggest obesity treatment. Yet, many physicians had an ambivalent attitude towards obesity management.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-022-01811-x.

Personal Health Practices and Perceptions of Lifestyle Counseling and Preventive Services Among Residents

Background. Primary care residents are expected to provide lifestyle counseling and preventive services for patients with chronic diseases; also, physicians’ personal lifestyle practice impacts patient care. The purpose of this article is to assess healthy lifestyle behaviors and attitudes to engage in lifestyle counseling and preventive services among residents and fellows in different training levels and specialty. Methods. A cross-sectional pilot study was conducted on medical residents and fellows (n = 57). Surveys collected information on lifestyle behaviors and perceptions of lifestyle counseling and preventive services. Comparisons of study measures were made across residents’ specialty and training levels. Fisher’s exact and analysis of variance tests were used for statistical analysis. Results. There were several significant differences in perceptions of counseling and screening by specialty and training level. There were no significant differences in personal lifestyle behaviors between all resident specialties and training levels. Conclusion. Our findings suggest that there are opportunities to improve healthy lifestyle behaviors and perceptions of lifestyle counseling and preventive services among residents in different specialties and training levels. This knowledge can inform development of training programs in lifestyle and preventive medicine practice during residency and fellowship.

Beyond Calorie Tracking: A Pilot Trial of a Remotely Delivered Behavioral Weight Loss Intervention Using an Ad Libitum Plant-Based Diet (Preprint)

Background

Many traditional lifestyle interventions use calorie prescriptions, but most individuals have difficulty sustaining calorie tracking and thus weight loss. In contrast, whole food plant-based diets (WFPBDs) have previously shown significant weight loss without this issue. However, most WFPBD interventions are face-to-face and time-intensive, and do not leverage gold standard behavioral strategies for health behavior change.

Objective

This open pilot trial was the first to evaluate the feasibility of a fully featured, remotely delivered behavioral weight loss intervention using an ad libitum WFPBD.

Methods

Over 12 weeks, participants (N=15) with overweight or obesity received a newly designed program that integrated behavioral weight loss and a WFPBD prescription via weekly web-based modules and brief phone coaching calls. Assessments were performed at baseline, midtreatment (6 weeks), and after treatment (12 weeks).

Results

The intervention was rated as highly acceptable (mean 4.40 out of 5, SE 0.18), and attrition was low (6.7%). In all, intention-to-treat analyses revealed that 69% (10.4/15) of the participants lost 5% of their weight (mean –5.89, SE 0.68 kg). Predefined benchmarks for quality of life were met.

Conclusions

A pilot digital behavioral weight loss intervention with a non–energy-restricted WFPBD was feasible, and the mean acceptability was high. Minimal contact time (80-150 minutes of study interventionist time per participant over 12 weeks) led to clinically relevant weight loss and dietary adherence for most participants (10.4/15, 69% and 11.8/15, 79%, respectively), and quality of life improvements (reliable change indices >1.53). We hope that this work will serve as a springboard for future larger scale randomized controlled studies evaluating the efficacy of such programs for weight loss, dietary change, and quality of life.

Trial Registration

ClinicalTrials.gov NCT04892030; https://clinicaltrials.gov/ct2/show/NCT04892030

Obesity is a chronic disease. Positioning statement of the Diabetes, Obesity and Nutrition Workgroup of the Spanish Society of Internal Medicine (SEMI) for an approach centred on individuals with obesity

BACKGROUND

Obesity is a chronic, complex and multifactorial metabolic disease involved in the development of chronic noncommunicable diseases such as type 2 diabetes mellitus, cardiovascular disease and cancer. The care of individuals with obesity is an essential part of the holistic approach provided by internal medicine to patients.

MATERIAL AND METHODS

Between September 2019 and January 2020, we distributed an online survey to the members of the Spanish Society of Internal Medicine. We prepared a Strengths, Weaknesses, Opportunities, and Threats analysis using the responses and, using the nominal group technique, developed the recommendations.

RESULTS

We obtained 599 responses. The respondents mean age was 44.4 ± 11 years, and 52.1% were women. Some 91.8% of the internists evaluate their patients to rule out the comorbidities associated with obesity, mainly type 2 diabetes mellitus (96.2%), cardiovascular disease (88.9%) and obesity-associated hypoventilation syndrome (73%), among others. Some 79.9% provided indications on lifestyle changes. Some 64.1% and 74.9% of the respondents knew the indications for the drugs and bariatric surgery, respectively. Some 93.8% and 83% of the respondents considered obesity and excess weight a chronic disease, and 88.7% considered it a disease of specific interest to internists, who should take an active and leading role in its treatment (85.3%).

CONCLUSIONS

The objective of the present document is to determine the degree of understanding and sensitivity of internists regarding the management of obesity and to develop a consensus of recommendations for the Spanish Society of Internal Medicine based on the scientific evidence and the opinion of its members.

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.

Health system barriers to accessing care for children with weight issues in New Zealand: An interview-based study

OBJECTIVE

To identify barriers created and maintained by the health system affecting engagement in a family-based multidisciplinary healthy lifestyle programme for children and adolescents in New Zealand.

METHODS

We conducted 64 semi-structured interviews with participants of the programme (n = 71) with varying levels of engagement, including those who declined contact after their referral. Half the interviews were with families with Māori children, allowing for appropriate representation. Interviews were analysed using thematic analysis.

RESULTS

Five health system factors affecting engagement were identified: the national policy environment, funding constraints, lack of coordination between services, difficulty navigating the health system, and the cost of primary health care.

CONCLUSIONS

Engaging with a health system that creates and maintains substantial barriers to accessing services is difficult, affecting programme engagement, even where service-level barriers have been minimised. Lack of access remains a crucial barrier to improved health outcomes for children and their families experiencing childhood obesity in New Zealand. There is a need for comprehensive approaches that are accompanied by a clear implementation strategy and coordinated across sectors.

Motivation and Problem Solving Versus Mobile 360° Videos to Promote Enrollment in the National Diabetes Prevention Program's Lifestyle Change Program Among People With Prediabetes: Protocol for a Randomized Trial

Background

More than 88 million Americans are at risk of developing type 2 diabetes mellitus (T2DM). The National Diabetes Prevention Program’s Lifestyle Change Program (DPP LCP) has been shown to be effective in reducing the risk of progressing from prediabetes to T2DM. However, most individuals who could benefit from the program do not enroll.

Objective

The aim of this trial is to test the real-world efficacy of 3 mobile phone–based approaches to increasing enrollment in the DPP LCP including a best-practice condition and 2 novel approaches.

Methods

We will conduct a 3-armed randomized clinical trial comparing enrollment and 1-month engagement in the DPP LCP among adults with prediabetes from 2 health care settings. Participants in the best-practice condition will receive SMS-based notifications that they have prediabetes and a link to a website that explains prediabetes, T2DM, and the DPP LCP. This will be followed by a single question survey, “Would you like the DPP LCP to call you to enroll?” Participants in the 2 intervention arms will receive the same best-practice intervention plus either 2 mobile 360° videos or up to 5 brief phone calls from a health coach trained in a motivational coaching approach known as Motivation and Problem Solving (MAPS). We will collect measures of diabetes-related knowledge, beliefs in the controllability of risk for T2DM, risk perceptions for T2DM, and self-efficacy for lifestyle change pre-intervention and 4 weeks later. The primary outcomes of the study are enrollment in the DPP LCP and 4-week engagement in the DPP LCP. In addition, data on the person-hours needed to deliver the interventions as well as participant feedback about the interventions and their acceptability will be collected. Our primary hypotheses are that the 2 novel interventions will lead to higher enrollment and engagement in the DPP LCP than the best-practice intervention. Secondary hypotheses concern the mechanisms of action of the 2 intervention arms: (1) whether changes in risk perception are associated with program enrollment among participants in the mobile 360° video group and (2) whether changes in self-efficacy for lifestyle change are associated with program enrollment among participants in the MAPS coaching group. Finally, exploratory analyses will examine the cost effectiveness and acceptability of the interventions.

Results

The project was funded in September 2020; enrollment began in February 2021 and is expected to continue through July 2022.

Conclusions

We are conducting a test of 2 novel, scalable, mobile phone–based interventions to increase enrollment in the DPP LCP. If effective, they have tremendous potential to be scaled up to help prevent T2DM nationwide.

Trial Registration

ClinicalTrials.gov NCT04746781; https://clinicaltrials.gov/ct2/show/NCT04746781

International Registered Report Identifier (IRRID)

DERR1-10.2196/28884

Giving "prescriptions" for paediatric weight management follow-up in primary care

The American Academy of Paediatrics recommends that primary care paediatricians "prescribe" follow-up for weight management between well child checks. We sought to describe rates and predictors of prescribed and actual clinic attendance for weight management in primary care in a predominantly low-income population. A chart review was performed at a large, hospital-based, primary care clinic, where a treatment algorithm for obesity exists. Eligible children were 6 to 12 years of age with a body mass index (BMI) ≥85th percentile and seen for a well child check in 2014. Primary outcomes were the physician prescribing follow-up in primary care and the patient returning for weight management. Multivariable logistic regression was used to identify predictors of prescribing follow-up and predictors of return. Participants included 1339 patients: mean age 9 years (SD: 1.8 years); 53% female; 79% Black; 89% Medicaid-insured; 56% with an obese BMI (vs overweight). Twenty-seven percent of patients were prescribed follow-up in primary care, of which 13% returned (only 4% of the original sample). The odds of the physician prescribing follow-up were greater if the child had obesity (vs overweight), was older, female or non-Medicaid insured. Older and non-Black patients had greater odds of returning. Patients prescribed follow-up within 2 months or less (vs 3-6 months) were also more likely to return (aOR 2.66; CI: 1.34, 5.26). Rates of prescription for weight management in primary care are low and few patients return, even when follow-up is prescribed. Prescribing follow-up at shorter intervals from the index visit (≤ 2 months) may improve patient return.

The Importance of Health Values Among Health Care Providers

Medical professionals' healthy eating and physical activity behaviors are likely to wane as other life events and everyday pressures increase. This is vital because as health behaviors decrease, the likelihood that this topic is addressed with patients also decreases. Increased training to improve health care providers' knowledge about lifestyle behaviors may be inadequate to actually bring about a healthier lifestyle. The area of personal identity and value formation may shed light on a significant barrier in this area. Developing health care professionals who have values consistent with a healthy diet and physical activity, instead of just being informed about it, would increase the likelihood that healthy behavior changes are discussed with patients. Strategies to encourage value formation around healthy lifestyles among medical professionals are discussed.

A systematic review and thematic synthesis of qualitative studies exploring GPs' and nurses' perspectives on discussing weight with patients with overweight and obesity in primary care

Guidelines and evidence suggest primary care clinicians should give opportunistic interventions to motivate weight loss, but these rarely occur in practice. We sought to examine why by systematically reviewing qualitative research examining general practitioners' ('GPs') and nurses' views of discussing weight with patients. We systematically searched English language publications (1945-2018) to identify qualitative interview and focus group studies. Thematic methods were used to synthesise the findings from these papers. We synthesised the studies by identifying second-order themes (explanations offered by the original researchers) and third-order constructs (new explanations which went beyond those in the original publications). Quality assessment using the Joanna Briggs checklist was undertaken. We identified 29 studies (>601 GPs, nurses and GP trainees) reporting views on discussing weight with patients. Key second-order themes were lack of confidence in treatments and patients' ability to make changes, stigma, interactional difficulty of discussing the topic and a belief of a wider societal responsibility needed to deal with patients with overweight and obesity. The third-order analytical theme was that discussions about weight were not a priority, and other behavioural interventions, including those relating to smoking, often took precedent. GPs and nurses reported that noting body mass index measurements at every consultation alongside a framework to deliver interventions would likely increase the frequency and perceived efficacy of behavioural weight interventions. GPs and nurses acknowledge the importance of obesity as a health issue, but this is insufficient, particularly amongst GPs, for them to construe this as a medical problem to address with patients in consultations. Strategies to implement clinical guidelines need to make tackling obesity a clinical priority. Training to overcome interactional difficulties, regular weighing of patients and changing expectations and understanding of weight loss interventions are also probably required.

The Impact of Obesity on Surgically Treated Locoregional Melanoma

BACKGROUND

The impact of obesity on early-stage melanoma is poorly understood. We examined the impact of overweight and obesity on clinical outcomes in locoregional melanoma.

METHODS

Adults who underwent surgery at Emory University Healthcare between 2010 and 2017 for clinically stage I-II cutaneous melanoma, with known stage, height, and weight at the time of presentation, were identified. The relationship between body mass index (BMI) and clinicopathologic characteristics was assessed.

RESULTS

Of 1756 patients, 584 were obese (33.2%; BMI ≥ 30), 658 were overweight (37.5%; BMI ≥ 25 and < 30), and 514 were normal weight (29.3%; BMI < 25). Demographics associated with obesity included male sex (odds ratio [OR] 2.6, 95% confidence interval [CI] 2.1-3.3; p < 0.001) and lower income (OR 1.5, 95% CI 1.2-1.9; p = 0.003). Melanomas in obese patients were thicker (2.0 ± 0.2 mm) than in overweight (1.7 ± 0.1 mm) or normal-weight patients (1.4 ± 0.1 mm; p = 0.002). Ulceration, mitoses, BRAF status, and sentinel lymph node (SLN) status were not affected by obesity. In multivariable analysis, obesity independently predicted increased odds of pathologic stage II melanoma (vs. stage 0 or I; OR 1.9, 95% CI 1.4-2.7, p = 0.001), but not pathologic stage III melanoma (p > 0.05). At 33 months' median follow-up, obesity was not an independent predictor of stage-specific overall survival (p > 0.05).

CONCLUSION

Obese patients are nearly twice as likely as their normal-weight peers to present with thicker melanomas, but they have similar stage-specific overall survival and SLN positivity. Obesity may promote more aggressive growth of the primary tumor, and barriers to preventive care in obese patients may exacerbate later-stage presentation.

Mobile Virtual reality vs. Mobile 360 Video to Promote Enrollment in the Diabetes Prevention Program Amongst Hispanic Adults (Preprint)

Background

Hispanic adults are at increased risk of developing type 2 diabetes. The Diabetes Prevention Program (DPP) reduces the risk of developing type 2 diabetes; however, the rate of enrollment is very low.

Objective

The goal of this pilot project was to determine whether presenting brief motivational mobile videos in virtual reality vs 360° video has differential effects on risk perceptions and enrollment in the DPP.

Methods

Adults with prediabetes were recruited at a clinic serving a low-income Hispanic community. After consenting, the participants completed a baseline survey that collected information about demographics and risk perceptions. All participants then viewed 2 videos. Per random assignment, the videos were presented either using the participant’s smartphone alone (360° video) or were viewed with their smartphone in a virtual reality (VR) cardboard headset. Two weeks later, a follow-up survey collected measures of enrollment in the DPP, risk perceptions, health literacy, the importance of contextual factors related to the decision of whether to enroll in the DPP (eg, distance to the class), and qualitative feedback on the interventions. We used logistic regression to determine whether enrollment in the DPP differed by intervention mode, while accounting for health literacy and contextual factors related to the DPP. We used unpaired t tests to examine differences in change in risk perceptions between groups. Paired t tests were used to examine within-subject changes in risk perceptions.

Results

A total of 116 participants provided complete data. Most participants were middle-aged (mean age 44.6 years; SD 11.9) Hispanic (114/116), female (79/116), with low health literacy (mean score 12.3/20; SD 3.4). Enrollment in the DPP was 44/116 (37.9%) overall but did not differ by group (odds ratio for enrolling in VR group 1.78, 95% CI 0.75-4.3; P=.19). Individuals who rated the distance needed to travel to attend the DPP as more important were less likely to enroll in the DPP (odds ratio 0.56, 95% CI 0.33-0.92; P=.03). Risk perceptions did not differ by group (mean change in 360° video group -0.07, mean change in VR group 0.03, t=0.6, P=.54) and did not change within subjects (mean 0.02, t=0.21, P=.83). Participant feedback suggested that the videos are emotionally engaging and educational.

Conclusions

The videos presented in 360° video and mobile VR had equal efficacy in promoting enrollment in the DPP. Future work to rigorously evaluate this intervention, its mechanism of action, and potential moderators of the efficacy are discussed.

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.

Inspiring Medical Students to Choose Primary Care Through Lifestyle Medicine Education

Despite a growing interest in lifestyle medicine, students at most medical schools in the United States are not receiving enough nutrition education and training in the principles of lifestyle modification to be effective at applying this knowledge to real-world clinical practice. Moreover, the rising prevalence of chronic lifestyle-related diseases and the increasing deficit of primary care providers is overwhelming the US health care system. The need for primary care physicians is being circumvented by medical students' diminishing interest in primary care partly due to concerns about salary, prestige, and being too broad in focus. Students may also recognize that the pharmaceutically based management of chronic conditions and supplemental lifestyle recommendations are often fraught with nonadherence, resulting in the progression of disease states. However, some medical schools have incorporated the concepts and practice of lifestyle medicine into their curriculums. This integration has the potential to inspire medical students to choose a primary care specialty, because students become more adept at addressing and treating the root causes of chronic disease. Lifestyle medicine education can empower students interested in primary care to fulfill their initial desires to treat and heal that may have inspired them to want to become doctors in the first place.

Obesity is a chronic disease. Positioning statement of the Diabetes, Obesity and Nutrition Workgroup of the Spanish Society of Internal Medicine (SEMI) for an approach centred on individuals with obesity

INTRODUCTION

Obesity is a chronic, complex and multifactorial metabolic disease involved in the development of chronic noncommunicable diseases such as type 2 diabetes mellitus, cardiovascular disease and cancer. The care of individuals with obesity is an essential part of the holistic approach provided by internal medicine to patients.

MATERIAL AND METHODS

Between September 2019 and January 2020, we distributed an online survey to the members of the Spanish Society of Internal Medicine. We prepared a Strengths, Weaknesses, Opportunities, and Threats analysis using the responses and, using the nominal group technique, developed the recommendations.

RESULTS

We obtained 599 responses. The respondents mean age was 44.4±11 years, and 52.1% were women. Some 91.8% of the internists evaluate their patients to rule out the comorbidities associated with obesity, mainly type 2 diabetes mellitus (96.2%), cardiovascular disease (88.9%) and obesity-associated hypoventilation syndrome (73%), among others. Some 79.9% provided indications on lifestyle changes. Some 64.1% and 74.9% of the respondents knew the indications for the drugs and bariatric surgery, respectively. Some 93.8% and 83% of the respondents considered obesity and excess weight a chronic disease, and 88.7% considered it a disease of specific interest to internists, who should take an active and leading role in its treatment (85.3%).

CONCLUSIONS

The objective of the present document is to determine the degree of understanding and sensitivity of internists regarding the management of obesity and to develop a consensus of recommendations for the Spanish Society of Internal Medicine based on the scientific evidence and the opinion of its members.

Investigating the Relationship Between Fatherhood and Provider Weight-Related Practices and Counseling in Clinical Settings

OBJECTIVE

To assess whether weight-related practices and counseling between men and their medical providers are associated with the patient's fatherhood status.

METHODS

Using the 2015-2017 National Survey of Family Growth, logistic regression models were constructed to examine the odds of men being weighed, told a weight status, or referred for nutrition/exercise counseling during a medical visit in the previous year.

RESULTS

The sample included 2,562 men and 1,272 fathers. Overall, 90%, 76%, and 49% of fathers were weighed by a provider, told their weight status, and referred for nutrition/exercise counseling, respectively. There were no associations between fatherhood status and being weighed or provider weight status communication. Fathers were more likely to be referred for nutrition/exercise counseling compared with those without children during a medical (adjusted odds ratio, 1.61; 95% confidence interval, 1.003-2.583) or routine visit (adjusted odds ratio, 1.81; 95% confidence interval, 1.04-3.16).

CONCLUSIONS AND IMPLICATIONS

The increased likelihood of nutrition or exercise counseling referrals among fathers presents an opportunity to address obesity within families.

Identifying Opportunities for Advancing Weight Management in Primary Care

Objective: Much has been written about the patients' perspective concerning weight management in health care. The purpose of this survey study was to assess perspectives of primary care providers (PCPs) and nurses toward patient weight management and identify possible areas of growth. Patients and Methods: We emailed a weight management-focused survey to 674 eligible participants (437 [64.8%] nurses and 237 [35.2%] PCPs) located in 5 outpatient primary care clinics. The survey focused on opportunities, practices, knowledge, confidence, attitudes, and beliefs. A total of 219 surveys were returned (137 [62.6%] from nurses and 82 [34.4%] from PCPs). Results: Among 219 responders, 85.8% were female and 93.6% were white non-Hispanic. In this study, PCPs and nurses believed obesity to be a major health problem. While PCPs felt more equipped than nurses to address weight management (P < .001) and reported receiving more training than nurses (50.0% vs 17.6%, respectively), both felt the need for more training on obesity (73.8% and 79.4%, respectively). Although, PCPs also spent more patient contact time providing weight management services versus nurses (P < .001), the opportunity/practices score was lower for PCPs than nurses (-0.35 ± 0.44 vs -0.17 ± 0.41, P < .001) with PCPs more likely to say they lacked the time to discuss weight and they worried it would cause a poor patient-PCP relationship. The knowledge/confidence score also differed significantly between the groups, with nurses feeling less equipped to deal with weight management issues than PCPs (-0.42 ± 0.43 vs -0.03 ± 0.55, P < .001). Neither group seemed very confident, with those in the PCP group only answering with an average score of neutral. Conclusion: By asking nurses and PCP general questions about experiences, attitudes, knowledge, and opinions concerning weight management in clinical care, this survey has identified areas for growth in obesity management. Both PCPs and nurses would benefit from additional educational training on weight management.

Prevalence and Management of Adult Obesity in a Large U.S. Academic Health System

INTRODUCTION

Both medication and surgical interventions can be used to treat obesity, yet their use and effectiveness in routine clinical practice are not clear. This study sought to characterize the prevalence and management of patients with obesity within a large U.S. academic medical center.

METHODS

All patients aged ≥18 years who were seen in a primary care clinic within the Duke Health System between 2013 and 2016 were included. Patients were categorized according to baseline BMI as underweight or normal weight (<25 kg/m²), overweight (25-29.9 kg/m²), Class I obesity (30-34.9 kg/m²), Class II obesity (35-39.9 kg/m²), and Class III obesity (≥40 kg/m²). Baseline characteristics and use of weight loss medication were assessed by BMI category. Predicted change in BMI was modeled over 3 years. All data were analyzed between 2017 and 2018.

RESULTS

Of the 173,462 included patients, most were overweight (32%) or obese (40%). Overall, <1% (n=295) of obese patients were prescribed medication for weight loss or underwent bariatric surgery within the 3-year study period. Most patients had no change in BMI class (70%) at 3 years.

CONCLUSIONS

Despite a high prevalence of obesity within primary care clinics of a large, U.S. academic health center, the use of pharmacologic and surgical therapies was low, and most patients had no weight change over 3 years. This highlights the significant need for improvement in obesity care at a health system level.

The importance of language in engagement between health-care professionals and people living with obesity: a joint consensus statement

Obesity is a chronic condition that requires long-term management and is associated with unprecedented stigma in different settings, including during interactions with the health-care system. This stigma has a negative effect on the mental and physical health of people with obesity and can lead to avoidance of health care and disruption of the doctor-patient relationship. Considerable evidence exists to suggest that simply having a conversation about obesity can lead to weight loss, which translates into health benefits. However, both health-care practitioners and people living with obesity report apprehension in initiating this conversation. We have collaborated with stakeholders from Obesity UK, physicians, dieticians, clinical psychologists, obesity researchers, conversation analysts, nurses, and representatives from National Health Service England Diabetes and Obesity. This group has contributed to the production of this consensus statement, which addresses how people living with obesity wish to have their condition referred to and provides practical guidance for health-care professionals to facilitate collaborative and supportive discussions about obesity. Expert stakeholders consider that changes to language used at the point of care can alleviate the stigma of obesity within the health-care system and support improved outcomes for both people living with obesity and for the health-care system.

Auyeung A, Doyle F. A Systematic Review Protocol of the Barriers to Both Physical Activity and Obesity Counselling in the Secondary Care Setting as Reported by Healthcare Providers

Physical activity and obesity counselling have both been gaining increasing interest in preventive health and treatment. However, most healthcare professionals do not provide advice on these topics nearly as often as they should. There are many reasons for this. Common barriers for the provision of brief advice on physical activity and obesity in both primary and secondary care are lack of time, motivation and knowledge. Systematic reviews have been published on the barriers of physical activity and obesity counselling in the primary care setting, but there is no published work on the barriers present in secondary care. This systematic review aims to assess all published data that discuss the barriers of physical activity and obesity counselling as noted by healthcare providers in secondary care. Four databases will be searched using the same search strategy, and the findings will be compiled using the COM-B model to explore the frequency of a reported barrier. This systematic review will be beneficial not only to practicing healthcare providers, but also the educational and managerial staff of secondary care facilities, as it may highlight the need for further training to fill gaps in the provision of preventive healthcare.

Improving obesity management training in family medicine: multi-methods evaluation of the 5AsT-MD pilot course

BACKGROUND

Quality, evidence-based obesity management training for family medicine residents is needed to better support patients. To address this gap, we developed a comprehensive course based on the 5As of Obesity Management™ (ASK, ASSESS, ADVISE, AGREE, ASSIST), a framework and suite of resources to improve residents' knowledge and confidence in obesity counselling. This study assessed the course's impact on residents' attitudes, beliefs, and confidence with obesity counselling.

METHODS

The course combines lectures with a bariatric empathy suit experience, standardized and in-clinic patient practice, and narrative reflections. Using a multi-methods design we measured changes in 42 residents' attitudes, beliefs, and self-confidence and thematically analyzed the narrative reflections to understand residents' experience with the course content and pedagogy.

RESULTS

Following the course, residents reported improved attitudes towards people living with obesity and improved confidence for obesity counselling. Pre/post improvement in BAOP scores (n = 32) were significant (p < .001)., ATOP scores did not change significantly. Residents showed improvement in assessing root causes of weight gain (p < .01), advising patients on treatment options (p < .05), agreeing with patients on health outcomes (p < .05), assisting patients in addressing their barriers (p < .05), counseling patients on weight gain during pregnancy, (p < .05), counseling patients on depression and anxiety (p < .01), counseling patients on iatrogenic causes of weight gain (p < .01), counseling patients who have children with obesity (p < .05), and referring patients to interdisciplinary providers for care (p < .05). Qualitative analysis of narrative reflections illustrates that experiential learning was crucial in increasing residents' ability to empathically engage with patients and to critically reflect on implications for their practice.

CONCLUSION

The 5AsT-MD course has the potential to increase residents' confidence and competency in obesity prevention and management. Findings reflect the utility of the 5As to improve residents' confidence and competency in obesity management counselling.

An Investigation of Chiropractor-Directed Weight-Loss Interventions: Secondary Analysis of O-COAST

OBJECTIVE

The purpose of this study was to investigate weight-loss interventions offered by Canadian doctors of chiropractic to their adult patients.

METHODS

This paper reports a secondary analysis of data from the Ontario Chiropractic Observation and Analysis STudy (N_c = 42 chiropractors, N_p = 2162 patient encounters). Multilevel logistic regression was performed to assess the odds of chiropractors initiating or continuing weight management interventions with patients. Two chiropractor variables and 8 patient-level variables were investigated for influence on chiropractor-directed weight management. In addition, the interaction between the effects of patient weight and comorbidity on weight management interventions by chiropractors was assessed.

RESULTS

Around two-thirds (61.3%) of patients who sought chiropractic care were either overweight or had obesity. Very few patients had weight loss managed by their chiropractor. Among patients with body mass index equal to or greater than 18.5 kg/m², guideline recommended weight management was initiated or continued by Ontario chiropractors in only 5.4% of encounters. Chiropractors did not offer weight management interventions at different rates among patients who were of normal weight, overweight, or obese (P value = 0.23). Chiropractors who graduated after 2005 who may have been exposed to reforms in chiropractic education to include public health were significantly more likely to offer weight management than chiropractors who graduated between 1995 and 2005 (odds ratio 0.02; 95% CI [0.00-0.13]) or before 1995 (odds ratio 0.08; 95% CI [0.01-0.42]).

CONCLUSION

The prevalence of weight management interventions offered to patients by Canadian chiropractors in Ontario was low. Health care policy and continued chiropractic educational reforms may provide further direction to improve weight-loss interventions offered by doctors of chiropractic to their patients.

Use of Amulet in behavioral change for geriatric obesity management

Background

Obesity in older adults is a significant public health concern. Weight-loss interventions are known to improve physical function but risk the development of sarcopenia. Mobile health devices have the potential to augment existing interventions and, if designed accordingly, could improve one’s physical activity and strength in routine physical activity interventions.

Methods and results

We present Amulet, a mobile health device that has the capability of engaging patients in physical activity. The purpose of this article is to discuss the development of applications that are tailored to older adults with obesity, with the intention to engage and improve their health.

Conclusions

Using a team-science approach, Amulet has the potential, as an open-source mobile health device, to tailor activity interventions to older adults.

Including Lifestyle Medicine in Medical Education: Rationale for American College of Preventive Medicine/American Medical Association Resolution 959

Introduced by the American College of Preventive Medicine and released by the American Medical Association House of Delegates in 2017, Resolution 959 (I-17) supports policies and mechanisms that incentivize and/or provide funding for the inclusion of lifestyle medicine education and social determinants of health in undergraduate, graduate and continuing medical education. Resolution 959 was passed to help address the current healthcare costs of lifestyle-related, noncommunicable chronic diseases that exert a devastating economic burden on the U.S. healthcare system. Approximately 86% of $2.9 trillion is spent annually on obesity, cardiovascular disease, type 2 diabetes, and some cancers, with very poor return on investment for health outcomes. Lifestyle medicine provides an evidence-based solution to the noncommunicable chronic disease epidemic; however, medical education in lifestyle medicine is minimal to nonexistent. This paper provides the case for healthcare innovation to include lifestyle medicine in the prevention and treatment of noncommunicable chronic diseases. Our medical education system recommendation is to provide lifestyle medicine training for prevention and treatment of noncommunicable chronic diseases. Exemplar lifestyle medicine schools are showcased and guidance for reform is highlighted that can be used to aid lifestyle medicine integration across the medical school education continuum. With a transformation of curriculum and development of new policies to support a focus on lifestyle medicine education in medical education across the continuum, a new healthcare model could be successful against noncommunicable chronic diseases and U.S. citizen wellness could become a reality.

The role of oral health care professionals in preventing and managing obesity: A systematic review of current practices and perceived barriers

INTRODUCTION

There is a growing interest to expand the role of oral health care professionals in obesity prevention and management. The aim of this systematic review was to synthesise the evidence on current practices of, and perceived barriers to, oral health care professionals' involvement in obesity screening and management.

METHODS

Key search strings were developed and used in seven databases from inception through February 6, 2019. Data were screened against inclusion criteria, independently extracted, and quality appraised by two reviewers based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

RESULTS

Ten studies were included in this review. The practices of oral health care professionals in relation to obesity assessment, counseling, and specialist referrals were found to be very limited. Oral health care professionals believed in their role to support patients for achieving weight-loss goals, however just over one-third were trained in anthropometry. Perceived barriers included lack of time, limited knowledge or training, patients' unwillingness to listen to oral health care professionals' advice, and lack of appropriate specialist referrals.

CONCLUSION

Oral health care professionals are well-positioned and supportive in undertaking healthy weight interventions in their clinical practice; however, their practices are limited due to barriers such as lack of time, limited training and lack of referrals.

Factors affecting access and use of preventive and weight management care: A public health lens

Obesity is an important risk factor for various chronic diseases. While people with obesity use the health system more and incur higher costs, they may forego using preventive care services (e.g., gynecological cancer screenings) due to issues of service use and service access. The aim of this paper was to use a public health lens to elucidate system level factors that affect healthcare access and utilization for preventive and weight management care by patients with obesity. Some elucidated factors include lack of access to a Primary Care Provider (PCP) and multidisciplinary healthcare settings, gender of the PCP, duration of medical visits and health professionals' attitudes about obesity. We highlight potential strategies for leaders to use when improving access and use of health services by patients with obesity in Canada and the need for future empirical studies in this research area.

Patient perceptions of primary care providers' knowledge of bariatric surgery

As the rate of obesity continues to rise, primary care providers (PCPs) must be aware and informed of the treatment options available. Bariatric surgery is the most effective long-term treatment for weight loss and improvement of obesity-related comorbidities. The aim of this study was to assess patients' perception of their PCP's opinion, support and knowledge of bariatric surgery and changes over time. In 2009 and 2015, a 27-question survey was developed and mailed to patients who had undergone laparoscopic Roux-en-Y gastric bypass (LRYGB) at our institution. Statistical analysis included chi-square and Fisher's exact test for associations between categorical variables, Wilcoxon rank sum test for comparison of ordinal or continuous variables and sign test for comparison of paired ordinal variables. There were 680 and 1106 patients who met inclusion criteria and were mailed the 2009 and 2015 survey, respectively. The survey response rate was 47% in 2009 and 35% in 2015; 125 patients completed both surveys. In 2009 and 2015, 78% and 80% of patients described their PCP's opinion of bariatric surgery as "very supportive" (P = 0.64), and 29% and 40% described their PCP as "very knowledgeable" about bariatric surgery (P = 0.02), respectively. Post-operative support from PCPs was described as "very supportive" by 77% and 79% of patients in 2009 and 2015, respectively (P = 0.07). Overall, Ninety-seven percent of patients would repeat their LRYGB experience. The majority of patients perceived their PCP as being supportive of bariatric surgery. Physicians' knowledge of bariatric surgery could be improved by establishing more opportunities for education. While patients' perception of their PCP's knowledge increased, no significant improvements in PCP opinion or support of bariatric surgery were observed over time. Patients' willingness to repeat their experience with bariatric surgery remained high.

Flaxseed Supplementation Improves Anthropometric measurements, Metabolic, and Inflammatory Biomarkers in Overweight and Obese Adults

Abstract. Background: The aim of this study was to assess the effects of supplementation with flaxseed on anthropometric measurements, lipid profile, insulin resistance, and inflammatory biomarkers in overweight and obese adults.

Methods: Fifty overweight and obese adults with body mass index (BMI) of 30.72 ± 3.31 kg/m2 participated in this study. Participants were randomly assigned to take lifestyle advice or lifestyle advice plus 30 g/day milled flaxseed for 12 weeks. The primary outcome was body weight; secondary outcomes included other anthropometric parameters, lipid profile and inflammatory biomarkers.

Results: At the end of the study, the following significant mean differences were seen in flaxseed and control groups, respectively: weight [−9.36 vs. −3.09 kg; P < 0.001], BMI [−3.34 vs. −1.2 kg/m2; P < 0.001], triglyceride [−62.88 vs. −9.85 mg/dL; P < 0.001], total cholesterol [−32.2 vs. −14.95; P = 0.04], homeostatic model assessment (HOMA-IR) [1.25 vs. −0.32; P = 0.024], high sensitive- C reactive protein [−2.2 vs. −1.01 mmol/L; P < 0.001] and tumor necrosis factor-α [−1.34 vs. −0.14 Pg/mL; P = 0.005].

Conclusion: These results suggest that flaxseed supplementation in addition to lifestyle modification is significantly superior to lifestyle modification alone for weight loss. More studies with different dosages of flaxseed are needed to find the optimal dosage. This trial was registered at clinicaltrials.gov as NCT02410668.

Discussing Weight Management With Type 2 Diabetes Patients in Primary Care Using the Small Talk Big Difference Intervention: Protocol for a Randomized Controlled Trial

Background

Guidelines for the management of type 2 diabetes universally recommend that adults with type 2 diabetes and obesity be offered individualized interventions to encourage weight loss. Yet despite the existing recommendations, provision of weight management services is currently patchy around the United Kingdom and where services are available, high attrition rates are often reported. In addition, individuals often fail to take up services, that is, after discussion with a general practitioner or practice nurse, individuals are referred to the service but do not attend for an appointment. Qualitative research has identified that the initial discussion raising the issue of weight, motivating the patient, and referring to services is crucial to a successful outcome from weight management.

Objective

Our aim was to evaluate the effectiveness of an Internet-based training program and practice implementation toolkit with or without face-to-face training for primary care staff. The primary outcome is the change in referral rate of patients with type 2 diabetes to National Health Service adult weight management programs, 3 months pre- and postintervention.

Methods

We used the Behavior Change Wheel to develop an intervention for staff in primary care consisting of a 1-hour Internet-based eLearning package covering the links between obesity, type 2 diabetes, and the benefits of weight management, the treatment of diabetes in patients with obesity, specific training in raising the issue of weight, local services and referral pathways, overview of weight management components/ evidence base, and the role of the referrer. The package also includes a patient pamphlet, a discussion tool, a practice implementation checklist, and an optional 2.5-hour face-to-face training session. We have randomly assigned 100 practices in a 1:1 ratio to either have immediate access to all the resources or have access delayed for 4 months. An intention-to-treat statistical analysis will be performed.

Results

Recruitment to the study is now complete. We will finalize follow-up in 2018 and publish in early 2019.

Conclusions

This protocol describes the development and randomized evaluation of the effectiveness of an intervention to improve referral and uptake rates of weight management programs for adults with type 2 diabetes. At a time when many new dietary and pharmacological weight management interventions are showing large clinical benefits for people with type 2 diabetes, it is vital that primary care practitioners are willing, skilled, and able to discuss weight and make appropriate referrals to services.

Trial Registration

ClinicalTrials.gov NCT03360058; https://clinicaltrials.gov/ct2/show/NCT03360058 (Archived by WebCite at http://www.webcitation.org/74HI8ULfn)

International Registered Report Identifier (IRRID)

DERR1-10.2196/12162

Factors influencing medical student self-competence to provide weight management services

This study aimed to identify factors associated with high obesity care self-competence among US medical students. The authors performed a cross-sectional analysis of 2014 survey data on fourth year medical students collected online as part of the Medical Student Cognitive Habits and Growth Evaluation Study (CHANGES). Independent variables included quality and quantity of interaction with patients and peers with obesity; hours of communication and partnership skills training; negative remarks against patients with obesity by supervising physicians, and witnessed discrimination against patients with obesity. The dependent variable was self-competence in providing obesity care. Of 5823 students invited to participate, 3689 (63%) responded and were included in our analyses. Most students were white (65%), half were women and 42% had high self-competence in caring for patients with obesity. Factors associated with high self-competence included increased interaction with peers with obesity (39% vs. 49%, P < 0.001) and increased partnership skills training (32% vs. 61%, P < 0.001). Increased partnership skills training and quantity of interactions with peers with obesity were associated with high student self-competence in providing obesity-related care to patients. Medical schools might consider increasing partnership skills training to improve students' preparedness and skill in performing obesity-related care.

The Phased Implementation of a National Telehealth Weight Management Program for Veterans: Mixed-Methods Program Evaluation

Background

The burden of obesity is high among US veterans, yet many face barriers to engaging in in-person, facility-based treatment programs. To improve access to weight-management services, the Veterans Health Administration (VHA) developed TeleMOVE, a home-based, 82-day curriculum that utilizes in-home messaging devices to promote weight loss in VHA patients facing barriers to accessing facility-based services.

Objective

The primary aim was to establish preliminary evidence for the program by comparing outcomes for TeleMOVE with standard, facility-based MOVE weight-management services (group, individual modalities) over the evaluation period based on the number of patients enrolled per site and the program’s clinical effectiveness, as demonstrated by average weight lost per patient. The secondary aim was to understand factors influencing TeleMOVE implementation variability across demonstration sites to develop recommendations to improve national program dissemination.

Methods

We employed a formative mixed-methods design to evaluate the phased implementation of TeleMOVE at 9 demonstration sites and compare patient- and site-level measures of program uptake. Data were collected between October 1, 2009 and September 30, 2011. Patient-level program outcomes were extracted from VHA patient care databases to evaluate program enrollment rates and clinical outcomes. To assess preliminary clinical effectiveness, weight loss outcomes for veterans who enrolled in TeleMOVE were compared with outcomes for veterans enrolled in standard MOVE! at each demonstration site, as well as with national averages during the first 2 years of program implementation. For the secondary aim, we invited program stakeholders to participate in 2 rounds of semistructured interviews about aspects of TeleMOVE implementation processes, site-level contextual factors, and program delivery. Twenty-eight stakeholders participated in audio-recorded interviews.

Results

Although stakeholders at 3 sites declined to be interviewed, objective program uptake was high at 2 sites, delayed-high at 2 sites, and low at 5 sites. At 6 months post enrollment, the mean weight loss was comparable for TeleMOVE (n=417) and MOVE! (n=1543) participants at −5.2 lb (SD 14.4) and −5.1 lb (SD 12.2), respectively (P=.91). All sites reported high program complexity because TeleMOVE required more staff time per participant than MOVE! due to logistical and technical assistance issues related to the devices. High-uptake sites overcame implementation challenges by leveraging communication networks with stakeholders, adapting the program to patient needs whenever possible, setting programmatic goals and monitoring feedback of results, and taking time to reflect and evaluate on delivery to foster incremental delivery improvements, whereas low-uptake sites reported less leadership support and effective communication among stakeholders.

Conclusions

This implementation evaluation of a clinical telehealth program demonstrated the value of partnership-based research in which researchers not only provided operational leaders with feedback regarding the effectiveness of a new program but also relevant feedback into contextual factors related to program implementation to enable adaptations for national deployment efforts.

Primary care provider management of patients with obesity at an integrated health network: A survey of practices, views, and knowledge

BACKGROUND

Obesity is a serious health problem that affects a wide range of patients and disease processes.

OBJECTIVE

The purpose of this study is to evaluate perceptions, knowledge, and practice habits of primary care providers (PCPs) regarding the care of patients with obesity, including barriers to effective care and their experience with bariatric surgery in our integrated health network.

SETTING

Integrated health network.

METHODS

A 16-question survey was distributed electronically to 160 PCPs at our integrated health network. Results were analyzed to identify attitudes, knowledge, practice habits, and bariatric surgery referral patterns while treating patients with obesity.

RESULTS

Among 160 PCPs, 45 (28.1%) responded. Specialty, sex, patient population, insurance accepted, and practice years of PCPs were reported. Most PCPs reported "always" calculating patient body mass index (88.9%) with only 13.3% "always" discussing the body mass index results. Respondents most frequently prescribed diet and exercise to patients with obesity and rarely prescribed medications, with bariatric surgery referrals falling between the two. PCPs viewed management of obesity as the responsibility of the patient (97.6%) and the PCP (100%). Ninety-three percent felt obesity is a common diagnosis in their practice, but no one correctly identified the prevalence of obesity in our region. Respondents demonstrated adequate knowledge regarding medical consequences of obesity. A majority was able to identify the correct eligibility criteria for bariatric surgery, as well specific medical problems that can improve or be eliminated postoperatively. While 61.9% of respondents were aware of free weight loss and bariatric informational sessions offered, 28.6% reported that they were unfamiliar with existing bariatric surgeons. One respondent was not aware of any bariatric surgery performed. Some PCPs reported prior negative experiences with post-bariatric surgery patients, and thus were hesitant to refer additional patients.

CONCLUSIONS

PCPs report discussing an obesity diagnosis with patients but are not always using body mass index in that discussion. They most often prescribe lifestyle modification as treatment for patients, which they believe to be most effective to treat obesity. However, they report only one third of their patients are motivated to lose weight. Additionally, they demonstrate appropriate knowledge of indications and benefits of bariatric surgery. A majority of the PCPs is aware of weight loss informational sessions and bariatric services provided within our integrated health network, but almost one third were unable to identify a surgeon, a possible target for improved relationships. Barriers to care include patient motivation and insurance coverage.

Nutrition and obesity care in multidisciplinary primary care settings in Ontario, Canada: Short duration of visits and complex health problems perceived as barriers

Nutrition care in the primary care setting is integral in obesity management, but there is a substantial gap between patients who would benefit from this service and those receiving it. This study provides an in-depth understanding of how relatively new multidisciplinary primary care settings may be affecting nutrition care practices of family physicians and nurse practitioners. This qualitative comparative case study sought to assess nutrition care practices in three different types of multidisciplinary clinics (2 Family Health Teams, 3 Community Health Centers, 1 Nurse Practitioner-Led Clinic) in Ontario, Canada. Individual semi-structured interviews were conducted with nurse practitioners (n = 13) and family physicians (n = 7) in fall 2017. Data analysis was conducted using NVivo Software. The integrated approach was used for elucidating codes and themes. Findings suggest that suboptimal duration of medical visits and increasing prevalence of complex patients were reported by most participants and were perceived as barriers for addressing nutrition and obesity. However, improved nutrition care was fostered through Electronic Medical Records, primary care providers' positive attitude towards nutrition and cost-free dietitian services at point of access. Site-specific challenges, such as duration of medical visits, incentive programs, access to dietitians on site, and continued professional development could enhance nutritional care for weight management in these multidisciplinary primary care settings.

The perspectives of pre-frail and frail older people on being advised about exercise: a qualitative study

BACKGROUND

Exercise is considered to be the most effective strategy to treat, prevent and delay frailty, a prevalent geriatric syndrome observed in clinical practice. Encouraging frail older people to take up exercise is crucial in the management of this condition. The study aimed to explore pre-frail and frail older peoples' perspectives in relation to being advised about exercise and their perceptions of the general practitioners' (GPs) role in promoting exercise for older people.

METHODS

Semi-structured interviews were conducted with 12 community-dwelling older (median age 83 years) participants screened pre-frail or frail using the FRAIL Screen. Their attitudes towards exercise, the advice received, their access to relevant information and their perceptions of the GP's role in promoting exercise were explored. Thematic analysis was conducted to analyse data.

RESULTS

The majority of participants had a positive attitude towards exercise, and many participants indicated a preference for being advised firstly by their GPs and then other healthcare professionals. Participants living in the community reported difficulties in accessing information on exercise and indicated that local governments and GP practices should promote exercise for older people more actively. Participants living in retirement villages, however, reported having access to relevant information and being encouraged to participate in exercise.

CONCLUSION

This research identified a gap in current practice, demonstrating that GPs, healthcare providers and local governments should promote exercise for older people more actively. Convincing health professionals to encourage regular exercise among their older patients would provide an opportunity to avoid and manage frailty in this population.

Knowledge, Attitudes, and Practice of In-Patient Physiotherapists in Ontario Regarding Patients Who Are Super-Morbidly Obese

Purpose: This article describes the knowledge, attitudes, and practice of in-patient physiotherapists in Ontario regarding the treatment of patients who are super-morbidly obese (SMO; i.e., those whose BMI is >50). Method: A 62-item questionnaire was developed to assess demographics, sources of knowledge, current practice, and attitudes such as confidence, willingness, and the perceived effectiveness of treatment. It was distributed electronically using FluidSurveys. All physiotherapists working in a clinical role with adults in an in-patient setting in Ontario were eligible to participate. Results: A total of 276 physiotherapists completed the survey. Most of them had learned about the treatment from non-structured sources such as clinical experience. More than half (52%) of the participants disagreed that their place of employment was well prepared to facilitate the treatment of patients who are SMO. The majority of respondents were confident in treating these patients, were willing to treat them (82%), and believed that physiotherapy would improve at least one health outcome (96%) for them; however, 46% were reluctant to treat for fear of personal injury. Participants most commonly felt limited by lack of equipment and lack of staff to assist. Conclusions: Physiotherapists have positive attitudes toward treating patients who are SMO, and increased equipment and staff to assist, as well as appropriate education, may decrease the fear of injury for physiotherapists while treating these patients and improve health outcomes for them.

Current Weight Management Approaches Used by Primary Care Providers in Six Multidisciplinary Healthcare Settings in Ontario

BACKGROUND

Obesity management in primary care has been suboptimal due to lack of access to allied health professionals, time, and resources.

PURPOSE

To understand the weight management approaches used by primary care providers working in team-based settings and how they assess the most suitable approach for a patient.

METHODS

A total of 20 primary care providers (13 nurse practitioners and 7 family physicians) working in 6 multidisciplinary clinics in Ontario were interviewed. All interviews were recorded, transcribed verbatim, and coded using NVivo qualitative software. Conventional content analysis was used to inductively elucidate codes, which were then clustered into categories.

RESULTS

A referral to on-site programming was the most frequent weight management approach used. The pharmacological approach was underutilized due to adverse side effects and cost to patients. Primary care providers assessed the most suitable weight management approach based on patients': preference, level of motivation, income status and access to resources, body mass index and comorbidities, and previous weight loss attempts. Primary care providers perceived that referring to health professionals and educational resources were the approaches preferred by patients.

CONCLUSIONS

The team-based nature of these clinics allowed for referrals to various on-site professionals and/or programs. Some barriers to pursuing weight management avenues with patients were patient dependent.

Crucial conversations about weight management with healthcare providers: patients' perspectives and experiences

PURPOSE

To elicit patient experiences of weight management discussions with providers and provide recommendations for future weight-related discussions.

METHODS

1000 patients who recently saw their provider for non-weight specific appointments were mailed measures of demographics, self-reported height and weight, activity level, adherence, perceptions of and recommendations for weight-related discussions, and internalized weight bias. This study was primarily descriptive and utilized a mixed method design including collection of quantitative and qualitative data.

RESULTS

242 patients responded (24 % response rate); 32.4 % overweight (N = 72), 41.9 % obese (N = 93). 47 % of overweight and 71 % of obese patients recalled that their provider discussed weight; 92 % were motivated to follow recommendations and 89 % felt confident doing so. Most patients (75 %) would like their provider to be "very direct/straightforward" when discussing weight, and 52 % would be "not at all offended" if they were diagnosed as "overweight/obese." Most patients (63 %) reported being "extremely comfortable" discussing weight with providers. Patients with higher BMI had higher levels of internalized weight bias (p < .001) and wanted their provider to "discuss weight sensitively" (p < .05).

CONCLUSION

This study suggests that patients have important preferences that providers should be mindful of when discussing weight. While these discussions can be challenging, most patients report that they would be comfortable having these conversations directly and most would have enhanced motivation and confidence following these conversations. Communicating about weight is needed and desired by patients; doing so sensitively with those at higher weight is essential.

Perceptions of Barriers to Effective Obesity Care: Results from the National ACTION Study

OBJECTIVE

ACTION (Awareness, Care, and Treatment in Obesity maNagement) examined obesity-related perceptions, attitudes, and behaviors among people with obesity (PwO), health care providers (HCPs), and employer representatives (ERs).

METHODS

A total of 3,008 adult PwO (BMI ≥ 30 by self-reported height and weight), 606 HCPs, and 153 ERs completed surveys in a cross-sectional design.

RESULTS

Despite several weight loss (WL) attempts, only 23% of PwO reported 10% WL during the previous 3 years. Many PwO (65%) recognized obesity as a disease, but only 54% worried their weight may affect future health. Most PwO (82%) felt "completely" responsible for WL; 72% of HCPs felt responsible for contributing to WL efforts; few ERs (18%) felt even partially responsible. Only 50% of PwO saw themselves as "obese," and 55% reported receiving a formal diagnosis of obesity. Despite HCPs' reported comfort with weight-related conversations, time constraints deprioritized these efforts. Only 24% of PwO had a scheduled follow-up to initial weight-related conversations. Few PwO (17%) perceived employer-sponsored wellness offerings as helpful in supporting WL.

CONCLUSIONS

Although generally perceived as a disease, obesity is not commonly treated as such. Divergence in perceptions and attitudes potentially hinders better management. This study highlights inconsistent understanding of the impact of obesity and need for both self-directed and medical management.

Design and rationale of the medical students learning weight management counseling skills (MSWeight) group randomized controlled trial

Physicians have an important role addressing the obesity epidemic. Lack of adequate teaching to provide weight management counseling (WMC) is cited as a reason for limited treatment. National guidelines have not been translated into an evidence-supported, competency-based curriculum in medical schools. Weight Management Counseling in Medical Schools: A Randomized Controlled Trial (MSWeight) is designed to determine if a multi-modal theoretically-guided WMC educational intervention improves observed counseling skills and secondarily improve perceived skills and self-efficacy among medical students compared to traditional education (TE). Eight U.S. medical schools were pair-matched and randomized in a group randomized controlled trial to evaluate whether a multi-modal education (MME) intervention compared to traditional education (TE) improves observed WMC skills. The MME intervention includes innovative components in years 1-3: a structured web-course; a role play exercise, WebPatientEncounter, and an enhanced outpatient internal medicine or family medicine clerkship. This evidence-supported curriculum uses the 5As framework to guide treatment and incorporates patient-centered counseling to engage the patient. The primary outcome is a comparison of scores on an Objective Structured Clinical Examination (OSCE) WMC case among third year medical students. The secondary outcome compares changes in scores of medical students from their first to third year on an assessment of perceived WMC skills and self-efficacy. MSWeight is the first RCT in medical schools to evaluate whether interventions integrated into the curriculum improve medical students' WMC skills. If this educational approach for teaching WMC is effective, feasible and acceptable it can affect how medical schools integrate WMC teaching into their curriculum.