Mental Health, Obesity, and Racial Disparities
Obesity and Greenhouse Gas Emissions
In January we celebrated the 2-year anniversary of the release of the Lancet Commission on Obesity report, entitled “The Global Syndemic of Obesity, Undernutrition and Climate Change.” The report focuses on the contributions of the food and agriculture, urban design, land use, and transportation systems, and the triple duty solutions to mitigate their contributions to the Global Syndemic. For example, the transportation sector in the U.S.
Weight Can't Wait
The Weight Can't Wait guide fills the gap in obesity management training and provides healthcare professionals with a short, accessible, practical, and informative guide to effective obesity care.
Click here to go inside the guide!
Why Weight? Resources
Academy of Nutrition and Dietetics: Eat Right Radio offers podcasts on healthy eating and nutrition.
Alliance for a Healthier Generation, American College of Sports Medicine, and Bipartisan Policy Center: Teaching Nutrition and Physical Activity in Medical School focuses on options for improving medical education and training in topics that have an important role to play in the prevention and treatment of obesity and chronic diseases.
American Association of Diabetes Educators: This section brings together the professional opportunities AADE offers to give you the education, information and solutions you need for your patients and your practice.
American Association of Family Physicians: This organization’s ‘Obesity’ collection features content on weight and related issues, including bariatric surgery, childhood obesity, diet, exercise, lifestyle counseling, and weight loss maintenance. Topics include screening, diagnosis, prevention, treatment, complications, best practices, and patient education.
American Association of Pediatrics: Pediatric ePractice is an online-based office designed to help providers prime their offices for effective prevention, assessment, and treatment of childhood overweight and obesity. The resources are organized to align with the workflow of a typical office and the associated tasks that align to each room. Each room contains a variety of tools and resources informed by the expected context of that portion of a patient visit.
American Board of Obesity Medicine: This website provides information on certifications in obesity medicine, including information on exam details and preparation.
American College of Cardiology, The Obesity Society, and The American Heart Association: In collaboration with the National Heart, Lung, and Blood Institute and stakeholder and professional organizations, these groups developed clinical Guidelines for the Management of Overweight and Obesity in Adults
American College of Physicians: This organization’s practice assessment tool is a free quality improvement program that will assist providers in identifying, targeting, and implementing high value care in the treatment of patients with obesity.
Additionally, the ACP Foundation in conjunction with a team of experts, developed a diabetes self-management guide, Living with Diabetes. The guide covers diet, exercise, monitoring blood sugar, foot exams, insulin and other medicines. Other patient guides include, Make it Happen!, developed to help with the struggle of losing weight and making healthier choices. Available in English, Spanish and Chinese.
American College of Sports Medicine: ACSM publishes several books and multimedia resources for diverse audiences, including targeted information for health care professionals.
American Council on Exercise: Access tools you can utilize to help gauge readiness to change, chart progress, provide information about how your patients and clients can work to achieve small goals and ultimately, accomplish long-term, healthy change. Resources include biometric videos, assessment forms, and podcasts.
American Diabetes Association: The American Diabetes Association’s Resources for Professionals webpage contains resources for all health care professionals who work with patients with diabetes. Educational tools for providers and patients alike, and links to diabetes education resources can be found here. These resources include ready-made slide presentations, tool kits filled with both provider and patient materials, and enduring materials that include many multimedia self-learning opportunities.
American Institute for Cancer Research: The Tools You Can Use website offers healthy recipes, meal planning approaches, a nutrition hotline, information on the link between BMI and cancer, and access to AICR materials and health aids.
American Society for Nutrition: ASN strives to be the premier source of sound nutrition science information for health care professionals, policymakers, the media and the public. The organization's website contains blog entries, videos, and vignettes covering the most recent nutrition and research news.
Association of Clinicians for the Underserved: ACU offers resources for patients that encourage healthy lifestyles through healthy eating and physical activity.
Canadian Obesity Network: The Canadian Obesity Network’s 5As of Obesity Management program is a step-by-step framework for busy non-specialists who manage obesity in their patients. It is an easy-to-use roadmap that ensures sensitive, realistic, measurable, and sustainable obesity management strategies that focus on improving health and wellbeing, rather than simply aiming for numbers on a scale.
Centers for Disease Control: The CDC website offers recommendations, reports, fact sheets, brochures, and social media tools to help combat overweight and obesity.
Centers for Medicare and Medicaid Services: This educational tool from CMS provides information on Medicare preventive services, including Intensive Behavior Therapy for Obesity.
Change Talk: Developed by The American Academy of Pediatrics and Kognito, this online module and mobile app designed to help health care professional navigate challenging conversations with patients and their families. The app allows providers to practice Motivational Interviewing skills to address patient resistance and create actionable opportunities for behavior change.
National Patient Safety Foundation: Ask Me 3 is a patient education program designed to improve communication between patients and health care providers, encourage patients to become active members of their health care team, and promote improved health outcomes.
Obesity Action Coalition: OAC offers a plethora of educational resources including the Understanding Your Weight-loss Options brochure which offers safe and effective information for individuals wanting to address their weight and improve their health. The organization provides insights on how to establish realistic goals through SMART resolutions.
Obesity Action Coalition and the American College of Physicians: Excess Weight and Your Health — A Guide to Effective, Healthy Weight Loss features a guidebook and video to support those wanting to learn more about their weight and how it impacts their health.
Obesity Education Network: This website serves as an educational resource hub specifically for health care professionals. It supports providers by equipping them with the necessary tools to identify, diagnose, and manage patients with overweight or obesity.
The Obesity Society: The Treat Obesity Seriously campaign offers tools and resources to educate policymakers and support health care providers.
University of Michigan Center for Health Communications Research: BMi2 is a DVD that offers additional practice in the core skills of Motivational Interviewing, with a particular focus on preventing and treating pediatric obesity, including nuances of working with parents of young children as well as working directly with older children.
Rudd Center for Food Policy and Obesity: This resource provides examples of Motivational Interviewing techniques that can be used by providers to assess ambivalence and motivation for lifestyle changes in patients with overweight or obesity.
US National Library of Medicine, National Institutes of Health: Efficacy of commercial weight-loss programs: an updated systematic review.
Rose SA. Physician weight loss advice and patient weight loss behavior change: A literature review and meta-analysis of survey data. International journal of obesity (2005). 2013;37(1):118; 118-128; 128.
Bardia A, Holtan SG, Slezak JM, Thompson WG. Diagnosis of obesity by primary care physicians and impact on obesity management. Mayo Clin Proc. 2007;82(8):927-932.
Moyer V. Screening for and management of obesity in adults: U.S. preventive services task force recommendation statement. Ann Intern Med. 2012;157:373-378.
Puhl RM, Heuer CA. The stigma of obesity: a review and update. Obesity 2009;17:941-64.
ACPM. COACHING AND COUNSELING PATIENTS A Resource from the American College of Preventive Medicine. 1st ed. American College of Preventive Medicine. 2009:24. Accessed July 18, 2014.
National center for health statistics, 2012.
Jensen MD. 2013 AHA/ACC/TOS guideline for the management of overweight and obesity in adults. J Am Coll Cardiol 2013.
CDC. Losing weight. Healthy Weight Web site. Updated 2014.
Gunther S, Guo F, Sinfield P, Rogers S, Baker R. Barriers and enablers to managing obesity in general practice: A practical approach for use in implementation activities. Quality in primary care. 2012;20(2):93-103. Accessed 3 June 2014.
STOP Obesity Alliance. Weight in America survey. Harris Interactive. 2010.
Bardia A, Holtan SG, Slezak JM, Thompson WG. Diagnosis of obesity by primary care physicians and impact on obesity management. Mayo Clin Proc. 2007;82(8):927-932.
Puhl RM, Heuer CA. The stigma of obesity: a review and update. Obesity 2009;17:941-64.
Brownell K, Kersh R, Ludwig D et al. Personal responsibility and obesity: a constructive approach to a controversial issue. Health Affairs. 2010;29(3):379--387
Brownell K, Kersh R, Ludwig D et al. Personal responsibility and obesity: a constructive approach to a controversial issue. Health Affairs. 2010;29(3):379--387
Kahan S, Cheskin LJ. Obesity and Eating Behaviors and Behavior Change. In: Kahan S, et al. Health Behavior Change in Populations. Johns Hopkins University Press, Baltimore, MD, 2014.
Day F, Loos R. Developments in obesity genetics in the era of genome-wide association studies. Journal of nutrigenetics and nutrigenomics. 2011;4(4):222--238.
Gorkin D, Ren B. Genetics: Closing the distance on obesity culprits. Nature. 2014;507(7492):309--310.
Field AE. Relationship of a large weight loss to long-term weight change among young and middle-aged US women. International journal of obesity and related metabolic disorders. 2001;25(8)
Foster GD, et al. Arch Intern Med. 2001 sep 24;161(17):2133-9.
Puhl R.Motivating or stigmatizing? public perceptions of weight-related language used by health providers. International journal of obesity(2005). 2013;37(4):612; 612-619; 619.
Sutin AR, Terracciano A. PLoS One. 2013;8(7):e70048.
Baier, E. Obese patients prompt hospitals to adopt new equipment, protocols. MPR News. 2011.
Rudavsky, S. Hospitals super-sizing equipment for obese patients. The Indianapolis Star. 2013.
Rice S. Hospitals retrofit to better care for growing number of morbidly obese patients. Modern Healthcare. 2014.
Crook, K. Strategies for accommodating obese patients in acute care settings. Hammes Company. 2009.
Finley, D. Accommodating dental patients who live large. San Antonio Express News. 2012.
Haigh C. Health care community responding to obesity epidemic. Endocrine Today. Healiocom. 2009.
Polley S. The Obesity Problem in U.S. Hospitals: Article - The Hospitalist. The-hospitalistorg. 2006.
Ogden CL. Prevalence of childhood and adult obesity in the United States, 2011-2012. JAMA : the journal of the American Medical Association. 2014;311(8):806; 806-814; 814.
Vallis M, Piccinini--Vallis H, Sharma A, Freedhoff Y. Modified 5 As Minimal intervention for obesity counseling in primary care. Canadian Family Physician. 2013;59(1):27--31
CDC.gov Healthy Weight: Assessing Your Weight: BMI About Adult BMI. DNPAO. CDC. 2011.
Post R, Mainous A, Gregorie S, Knoll M, Diaz V, Saxena S. The influence of physician acknowledgment of patients' weight status on patient perceptions of overweight and obesity in the United States. Archives of internal medicine. 2011;171(4):316--321
Swift J, Choi E, Puhl R, Glazebrook C, Talking about obesity with clients: preferred terms and communications styles of UK pre-registration dieticians, doctors, and nurses. Patient education and counseling. 2013; 91(2):186-191.
Christie D, Channon S. The potential for motivational interviewing to improve outcomes in the management of diabetes and obesity in paediatric and adult populations: a clinical review. Diabetes, Obesity and Metabolism. 2014;16(5):381--387
ACPM.COACHING AND COUNSELING PATIENTS A Resource from the American College of Preventive Medicine. 1st ed. American College of Preventive Medicine.; 2009:24. Accessed July 18, 2014.
Miller W, Rollnick S. Motivational interviewing. Third ed. New York, NY: Guilford Press; 2012:482.
Stewart E, Fox C. Encouraging Patients to Change Unhealthy Behaviors With Motivational Interviewing: Family Practice Management. AAFP. 2011. Accessed July 20, 2014.
Pollak KI. Physician communication techniques and weight loss in adults. Am J Prev Med. 2010;39(4):321; 321-328; 328.
Schlair S. How to deliver high quality obesity counseling in primary care using the 5As framework. Journal of clinical outcomes management. 2012; 19(5).
Wadden TA, Womble LG, Sarwer DB, Berkowitz RI, Clark VL, Foster GD. Great expectations: "I'm losing 25 percent of my weight no matter what you say". J Consult Clin Psychol. 2003;71(6):1084-1089
Hall KD, Sacks G, Chandramohan D, et al. Quantification of the effect of energy imbalance on bodyweight. The Lancet. 378(9793):826-837.
AHA/ACC/TOS. (2013) Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: The Evidence Report.
Rao M. Do healthier foods and diet patterns cost more than less healthy options? A systematic review and meta-analysis. BMJ open. 2013;3(12)
Cawley J. The medical care costs of obesity: An instrumental variables approach. J Health Econ. 2012;31(1):219; 219-230; 230.
USDA, Center for Nutrition Policy and Promotion. Eating healthy on a budget: the consumer economics perspective. Choosemyplate.gov. 2011.
Coris E. Cultural competency in obesity. College of Public Health Obesity Lecture Series. University of South Florida. 2003.
Trigwell J, Watson P, Murphy R, Cable T, Stratton G. Addressing childhood obesity in black and racial minority (BRM) populations in Liverpool.2011.
Stevelos J,White W. Sexual abuse and obesity: What’s the link. Your Weight Matters Magazine. 2010;6.
Bleich SN, Gudzune KA, Bennett WL, Jarlenski MP, Cooper LA. How does physician BMI impact patient trust and perceived stigma? Prev Med.2013;57(2):120-124.
Why Weight? Tool Content
This page provides a summary of the Why Weight? discussion tool. To view the entire section within the guide, download the PDF.
Why Should Providers Discuss Weight With Patients?
Health care providers are uniquely situated to address overweight and obesity. Many patients want and even expect weight loss guidance from health care providers. Patients seek a trusting relationship with their providers, and many choose providers whom they believe have the confidence to raise difficult issues like obesity. In one survey, 85 percent of patients said they look for information about how to achieve and maintain a healthier weight on their own, and yet 57 percent of those trying to lose weight feel discouraged because of unsuccessful attempts to lose weight in the past.
Overcoming Barriers to Create Opportunities to Have Conversations About Weight
Providers report several challenges and barriers to addressing weight with their patients, as described below. While these are real concerns, many of these barriers are being addressed by structural changes in our health care system and new discoveries in obesity management.
Opportunity: While time limitations are relevant challenges for many clinical goals, including obesity management, productive interactions can be relatively short. Initial discussions will set the stage for ongoing conversation. Further, strategic use of a team-based approach, such as including dietitians or nurses and referral to obesity specialists, internet resources, or commercial programs, can extend providers’ impact.
Considerations for Fostering Effective Communication About Weight and Health
Many patients avoid or delay medical treatment due to concerns that their providers will not have furniture, equipment, or an environment that accommodates their needs. In a typical primary care setting, a significant proportion of patients are too heavy to fit into office furniture and medical equipment. In fact, recent data show that 14 percent of American adults have BMI > 35 kg/m2, the equivalent of carrying 75 lbs or more excess weight.
Beginning the Conversation
Weight and obesity are sensitive and personal topics. Discussing weight can be a difficult experience for the patient, leaving him or her open to feelings of embarrassment, fear, and blame. Start by listening. For patients who have not had experience with weight loss efforts, this may be the first time they have ever discussed their weight.
While many patients with overweight or obesity likely have attempted weight loss previously, there are also those who do not consider their weight to be a problem. For these patients in particular, it may be helpful to assess their readiness for behavioral change in order to inform the conversation.
Many providers express concern about offending patients by bringing up the topic of weight. There are many techniques to help start these conversations. For example, motivational interviewing (MI) is a collaborative, goal-oriented style of communication designed to assist the patient in attaining specific goals within an atmosphere of acceptance and compassion.
The Importance of Managing Expectations and Setting Goals
It’s important to work with patients collaboratively to develop weight and health-related goals. Many patients have unrealistic expectations of how much weight they will be able to lose. One study demonstrated that patients expected to lose nearly one-third of their body weight with diet and exercise, which is more weight than the average patient loses even with bariatric surgery.
Listening to and Understanding a Patient’s Situation and Context
Our choices and decisions are heavily influenced by the environment in which we live. Taking time to learn about patients’ everyday lives, including their home and work environments, interpersonal relationships, family dynamics, stressors, and cultural preferences, can lead to better understanding of the challenges they face and a more informed perspective from which to support them.
The Impact of Trauma and Need for Trauma-Informed Care
Studies largely have confirmed the association between traumatic childhood experiences or abuse and the development of eating disorders and obesity, especially severe obesity. One manifestation of this is binge eating disorder, which is three or four times more common in patients who report a history of childhood sexual abuse.
You may worry about how your own weight or health habits impact the discussion you have with your patient. Body image and concerns about weight affect all of us. Yet it’s important to remember that weight is about health, not appearance.
Why Weight? About
About The Tool
Weight is a complex and sensitive issue, and conversations about weight can be challenging. Many factors are at play, not least of which may include feelings of failure, shame, and concerns about being judged by health care providers. Many providers have concerns about how to begin conversations about weight, what words to use, and how to communicate about weight while supporting their patients in ways that are empowering and nonjudgmental. Providers report minimal, if any, training on obesity, inadequate resources for effective conversations, and insufficient clinical time to devote to conversations about weight. Research has shown that behavioral and medical treatment can be effective, but improvised and uninformed discussions may disengage, stigmatize, or shame patients, to the detriment of the provider-patient relationship, obesity treatment goals, and patient outcomes.
This provider discussion tool, developed by the Strategies to Overcome and Prevent (STOP) Obesity Alliance, addresses many of these concerns. Our goal is to help providers have more effective conversations about weight and health with their patients. The guide focuses on skills for building a safe and trusting environment with patients and facilitating open, productive conversations about weight. It also provides potential scenarios that providers may face and suggests ways to approach the conversations.
We began the development of the tool by conducting an audit of available materials and research regarding these issues. This information, provided in Appendix A, informed an expert roundtable convened in May 2014. Roundtable participants were from a range of backgrounds including obesity practice and research, primary care practice, nutrition education, women’s health, minority health, and the patient community. Our discussions focused on how to help providers initiate and sustain productive conversations about weight and health in real-world practice settings and the constraints that limited these conversations.
This tool has been reviewed by a selected panel of experts and members of the STOP Obesity Alliance.
Thank you for taking the time to read this guide. Engaging health care providers like you will improve conversations about weight and health and encourage people to conduct more active dialogues with their health care providers.
William H. Dietz, MD, PhD & Scott Kahan, MD, MPH
Credits & Acknowledgements
This guide was developed in partnership between the obesity research team at Milken Institute School of Public Health at the George Washington University and the STOP Obesity Alliance communications team at Chandler Chicco Agency:
- William H. Dietz, MD, PhD, George Washington University
- Scott Kahan, MD, MPH, George Washington University
- Cristy Gallagher, George Washington University
- Christine Petrin, George Washington University
- Kaushika Prakash, George Washington University
- Gina Mangiaracina, Chandler Chicco Agency
- Melissa Warren, Chandler Chicco Agency
- Sarah Slotnick, Chandler Chicco Agency
The STOP Obesity Alliance would like to thank and acknowledge the following individual experts and organizations for reviewing and providing input on the guide:
- Angela F. Ford, PhD, MSW, Black Women's Health Imperative
- April Barbour, MD, GW Medical Faculty Associates
- Arya Mitra Sharma, MD, PhD, FRCPC, University of Alberta
- Bradley J. Needleman, MD, FACS, Ohio State University Surgery, LLC
- Brook Belay, MD, MPH, Centers for Disease Control and Prevention
- Dawn K.Wilson, PhD, Society of Behavioral Medicine
- Donna Ryan, MD, Professor Emeritus, Pennington Biomedical Research Center
- Ginger Winston, MD, MPH, GW Medical Faculty Associates
- Joe Nadglowski, Obesity Action Coalition
- Marijane Hynes, MD, GW Medical Faculty Associates
- Patricia Nece
- Patrick O'Neil, PhD, Medical University of South Carolina
- Pepin Andrew Tuma, JD, Academy of Nutrition and Dietetics
- Samuel Lin, MD, PhD, MBA, American Medical Group Association
- Scott Butsch, MD, MSC, Massachusetts General Hospital
- Ted Kyle, RPh, MBA, The Obesity Society
- Wendy K. Nickel, MPH, American College of Physicians
About the Strategies to Overcome and Prevent (STOP) Obesity Alliance
The Strategies to Overcome and Prevent (STOP) Obesity Alliance is a collaboration of more than 80 consumer, provider, government, business, and health insurer organizations working to drive innovative and practical strategies that combat obesity. With an academic home at The George Washington University’s Milken Institute School of Public Health (GW), the Alliance focuses on developing evidence-based reports, policy recommendations and tools. William H. Dietz, M.D., Ph.D. is the director of the Alliance and head of the Sumner M. Redstone Global Center for Prevention and Wellness at GW. The Strategies to Overcome and Prevent (STOP) Obesity Alliance has received funding from its founding sponsor, Sanofi U.S. LLC, and its supporting sponsor Novo Nordisk Inc. Additional generous support has been provided by Eisai, Co., Ltd., Ethicon U.S. LLC, Takeda Pharmaceuticals U.S.A., Inc. and members of STOP. For more information, visit www.stopobesityalliance.org and follow the Alliance on Facebook and on Twitter.
Why Weight? Videos
This page provides a series of videos that accompany the Why Weight? discussion tool. These videos are meant to serve as a supplement to show productive and counterproductive conversation techniques.
Why Weight? Overview
Dr. Scott Kahan introduces the Why Weight? discussion tool and provides an overview of productive ways for health care providers to discuss the topic of weight and health with patients.
A Productive Conversation
In this video, Dr. Scott Kahan provides examples of positive ways to discuss lifestyle changes with a patient, including several motivational interviewing techniques.
What Not To Do
This video is an example of what not to do when discussing health and weight with patients. It is for teaching purposes only. The STOP Obesity Alliance, George Washington University, and Dr. Scott Kahan do not approve of the practices shown in this video.
Why Weight? Literature Review
We searched PubMed, Scopus, and Google Scholar for peer-reviewed journal articles, using search terms including: obesity treatment in primary care, obesity diagnosis, barriers to obesity treatment, obesity bias in primary care, obesity discussion tools, motivational interviewing techniques, and physician training in obesity. We additionally reviewed relevant public sources, including the National Center for Health Statistics, the Yale Rudd Center for Food Policy and Obesity, and previously published research conducted by STOP Obesity Alliance.
Most providers are not having instructive or satisfactory conversations with their patients about weight. Even when physicians have conversations about weight, patients do not necessarily come away from the experience with the information they need.
Why primary care? Primary care providers are an important source of information and guidance on health-related issues. Primary care physicians are uniquely situated to help address overweight and obesity.
Physician offices host over one billion patient visits each year, with visits to primary care physicians (PCPs) encompassing 56 percent of doctor visits.1
A person will visit his or her PCP an average of 1.8 times per year, providing these physicians with an excellent opportunity to regularly interact with a wide variety of patients.2
In 2012, 28 percent of primary care patients were overweight, and 35 percent were obese.3 Taken together, 63 percent of patients seen by a PCP have an unhealthy weight.
Physicians feel a responsibility to treat weight. In 2009, the STOP Obesity Alliance conducted a survey of 290 primary care physicians, assessing treatment of patients with overweight and obesity.4 The survey found that 89 percent of physicians agreed it was their responsibility to help a person with overweight lose weight.
Physicians are not diagnosing overweight and obesity in their patients.
The National Health and Nutrition Examination Survey (NHANES), a cross-sectional nationally representative study, found that only 45 percent of patients with a BMI greater than 25 were told by a physician that they were overweight.5 For those with a BMI over 30, 66 percent received an obesity diagnosis.
According to a study of 9,827 Mayo Clinic patients, 2,543 had a BMI indicating obesity, yet only 20 percent of these patients with obesity received an obesity diagnosis.6 The study also found that diagnosis was the strongest predictor in formulation of a weight management plan. Approximately 40 percent of patients who received an obesity diagnosis also received a treatment plan, while only 20 percent of patients with obesity that was undiagnosed received a management plan.7
Studies have shown that when physicians have weight-related discussions with their patients, the patients are able to recall the conversation with excellent accuracy and will increase their weight-loss efforts.
In a meta-analysis of 32 reports, all except one demonstrated a positive effect of PCP advice on patient engagement in weight-loss efforts.8
One study compared physician and patient reports of weight discussions with audio recordings of patient visits. Overall, physicians were 70 percent accurate in correctly recalling conversations they had with patients, while 67 percent of patients correctly summarized the visit.9 However, for discussions of weight only, these percentages increased greatly. Physicians had 97 percent accuracy and patients had 98 percent accuracy with congruence between the two groups of 95 percent.
Physicians who are struggling to discuss weight with their patients currently lack the necessary resources (most notably training, patient materials, and time) to treat patients with overweight and obesity.
PCPs have reported several common barriers to discussing and treating obesity.
Physicians cite time limitations, as well as avoiding referrals to services not covered by insurance, as reasons for avoiding weight counseling.10
In 2007, a focus group of 22 physicians representing internal medicine, family medicine, ob/gyn, and pediatrics, as well as four nurse practitioners, detailed the barriers they encounter in trying to treat obesity.11 Concerned by the lack of reimbursement for time spent on preventive procedures, physicians cited payment as the number one barrier to obesity treatment. Next were time constraints, followed by legal issues, inconsistency between guidelines and available resources, and concern that discussions regarding weight might be offensive or be perceived as “lecturing.” The focus group also discussed facilitators in obesity treatment, specifically mentioning patient materials like pamphlets and handouts, as well as “tool consistency,” with listed user-friendly resources and implementation of guidelines as examples.12
Training physicians to counsel patients can produce measurable patient outcomes; however, most PCPs lack training in treatment of overweight and obesity.
Half of the 23 residents in the New York University School of Medicine Primary Care Residency Program received a five hour obesity training curriculum based on the 5As model (assess, advise, agree, assist, and arrange). More than 15 percent of patients whose resident had specific training in obesity saw statistically significant weight loss. While this is not a particularly high percentage, only 5 percent of patients whose resident did not undergo obesity training saw the same weight loss results.13
A 2003 survey of 87 internal medicine residents found that 60 percent did not know the minimum BMI for diagnosing obesity, 69 percent did not recognize waist circumference as a reasonable measure of overweight/obesity, 39 percent incorrectly reported their own BMI, and only 44 percent felt qualified to treat patients with obesity.14
Similar results were seen with physicians in 2008. In a study observing competency in obesity treatment among internal medicine, pediatric, and psychiatric physicians, 48 percent could not adequately answer patient questions about obesity treatments and 39 percent could not adequately provide counseling.15
A STOP survey of 290 physicians representing general, family, and internal medicine found that 72 percent of those polled said no one in their practice had been trained to deal with obesity diagnosis and management.16 The sample of responses was weighted to be representative of the PCP population in the U.S. by using gender, number of years in practice, and regional demographics from the American Medical Association Masterfile.
There is confusion among physicians regarding their ability to treat obesity. In 2012, a group of 500 PCPs polled were split nearly down the middle, with 48 percent responding that dietitians and nutritionists were more qualified to help patients with obesity, while 41 percent believed physicians were the most qualified to help.17 Smaller percentages left the responsibility to endocrinologists, psychologists, and nurses. Interestingly, when asked about their abilities to treat obesity, 90 percent reported feeling confident in their weight counseling abilities, but only 44 percent reported success in helping their patients with obesity lose weight.18
Behavioral and medical treatment can be effective in certain patient populations, but improvised discussions run the risk of potentially stigmatizing or shaming patients, which can be detrimental to obesity treatment and patient outcomes.
Several studies have demonstrated a lack of respect that some physicians have for patients with obesity.
In a study of 40 physicians, higher BMI had a significant and negative correlation with respect; physicians reported “low respect” for 39 percent of their patients with overweight and obesity.19
In another study, 126 individuals with overweight and obesity admitted to feeling judged because of their weight.20 Of these, only 14 percent achieved significant weight loss, compared to 20 percent of individuals with overweight and obesity who reportedly did not feel judged because of their weight. Patients who felt judged by their PCP were more likely to attempt weight loss, but were not more likely to achieve clinically significant results. Unintentionally stigmatizing patients could negate otherwise effective treatment.
Lack of respect for patients with obesity can be seen as early as the post-graduate level. A group of 107 post-graduate students across several health disciplines, including physician assistants and medical residents, were asked questions about their attitudes toward patients with obesity.21 Weight bias was evident, with 65 percent of students reporting their patients with obesity were a target of negative attitudes by health providers.
Three key themes emerged in qualitative interviews among individuals living with obesity, health professionals, and policy makers22.
Blame as a devastating relation of power
Participants with obesity shared feelings of self-blame, shame and embarrassment, discussing their frustrations with failed attempts to lose weight and the absence of support. Health care providers viewed a lack of weight loss as an unwillingness to commit, voicing their disappointment in patients who are unable to lose weight. They also blamed themselves, describing feelings of powerlessness and inability to support or provide follow up.
Tensions in management
Both patients and health care providers described a lack of support from the health care system, and health providers in particular detailed the struggle to approach obesity management. Policy makers discussed the trend of shifting the focus from obesity to underlying issues like nutrition and physical activity, which means treatment is often overlooked in favor of prevention policies. If the physicians do not feel equipped to treat obesity and the system perpetuates a lack of interest in treatment, individuals are left alone to struggle with weight.
Prevailing conflicts in medical management discourse
Physicians are less likely to treat obesity alone; rather they work with patients living with both obesity as well as another diagnosed chronic health condition, indicating reluctance to accept obesity as a disease. Policy makers were hesitant to conceptualize obesity within a medical model, questioning whether medical treatment was necessary. Several policy makers suggest community health promotion was a better avenue to address obesity, referring to it as a “risk factor” rather than a “disease.”
Clear understanding of public preference and perception of weight terminology is crucial to creating an encouraging and informative weight counseling program. Physician wording can impact treatment, by either motivating or harming patient-physician relations.
A study of 1,064 participants, 62 percent of whom had overweight or obesity, asked which weight-related words participants found motivating and which they found stigmatizing.23 Desirable weight-related words were: weight, unhealthy weight, and overweight. Undesirable words were: morbidly obese, obese, and fat. These “blaming” words were so undesirable that 19 percent of patients said they would avoid future medical visits if this language was used consistently, and 21 percent said they would seek new doctors if they felt stigmatized.
While starting the discussion is important, utilizing specific communication techniques can provide a more effective approach to weight-related conversations.
A 2010 study analyzed 137 patient surveys following a PCP visit.24 The surveys assessed the physicians’ use of the 5As model (assess, advise, agree, assist, and arrange). Patients with higher levels of motivation reported receiving more 5As counseling than those with less motivation. Each additional counseling session was associated with higher odds of the patient being motivated to lose weight. On average, most of the 5As were employed less than once per visit, with a particular focus on assess over assist or arrange. Patient-centered approaches— responsiveness to individual needs, goals, and preferences—were also positively associated with intentions to eat better and exercise.
In an observational study of 461 patients with overweight or obesity, physicians’ use of interviewing techniques were coded from audio recordings of patient interactions and then compared to subsequent patient weight loss.25 In general, motivational interviewing (MI) techniques are:Although weight discussions did not necessarily lead to weight loss, the use of MI did successfully predict weight loss. Simply having the conversation is not enough to encourage patients to lose weight. How these conversations are conducted seems to be a much more powerful indicator of subsequent weight loss. Unfortunately, fewer than half of the observed physicians reported receiving training in behavioral counseling.26
Designed to motivate the ambivalent
Collaborative in nature
Understanding of the patient perspective
Accepting of patient motivation or lack of motivat'on
Meant to assist patients in finding their own solutions to their problems, thereby discovering their own motivation
Affirming of a patient’s freedom to change
Encouraging of “change statements”
Not judging, confronting, or providing advice without permission
Although weight discussions did not necessarily lead to weight loss, the use of MI did successfully predict weight loss. Simply having the conversation is not enough to encourage patients to lose weight. How these conversations are conducted seems to be a much more powerful indicator of subsequent weight loss. Unfortunately, fewer than half of the observed physicians reported receiving training in behavioral counseling.26
A separate study compared weight-loss efforts of 55 participants with obesity, half of whom engaged in a behavioral weight-loss program and half of whom engaged in the same behavioral program as well as MI sessions.27 Both groups attended weekly, small-group sessions for 20 weeks. The program encouraged gradual weight loss, progressively increasing physical activity, and decreased fat intake. Those in the MI group also attended a weekly session with a clinical psychologist who was trained in motivational interviewing techniques. Those in the MI group lost significantly more weight than the behavioral weight loss group alone and also engaged in significantly more planned physical activity (+68 minutes/week).
Finally, a study observing women with overweight and obesity saw that those receiving MI in addition to a regular behavioral program attended significantly more sessions and turned in more food diaries than the standard group.28 While no significant weight loss differences were seen between the two groups, the results suggest MI enhances adherence to treatment and recommendations.
Some researchers have developed tools designed to provide assistance to PCPs treating obesity. Though few, these real world applications have been shown to effectively educate patients through informed conversations with their physicians, while simultaneously removing or lessening other barriers to obesity treatment.
The best way to ensure physicians are employing positive communication methods is to provide them with the necessary resources to discuss overweight and obesity.
A simple electronic reminder can have a profound impact on rates of weight counseling in pregnant women. In one study, the rate of counseling seen in ob/gyn and family medicine practices increased from 3 percent to 51 percent after an intervention that utilized a pre-set alert was added to the Electronic Medical Record (EMR) system.29 When a patient’s BMI indicated obesity, a popup window appeared on the computer screen with a counseling reminder and a detailed, interdisciplinary script. Before the alert was added to the electronic system, only 4 percent of patients had determined a numerical weight goal with her physician, compared to the 57 percent who discussed a concrete goal after the intervention.
The Vermont Department of Health, along with The University of Vermont College of Medicine, created a primary care weight management tool kit.30 This tool kit was tested in Wisconsin primary care clinics. The tool kit is essentially a clinic algorithm to guide visits. It also includes education on MI techniques for PCPs. Providers found the tool kit helpful, straightforward, and easy to use, while 98 percent of patients with a BMI over 25 found the conversations generated by the tool kit to be useful. In fact, 90 percent agreed they had received information they felt would help them meet their weight loss goals. Nearly 70 percent of physicians reported that the nursing staff should be trained in the tool kit as well. Unfortunately, a majority of the physicians found the tool kit to be excessively time consuming.
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