Research article
Obesity Counseling and Guidelines in Primary Care: A Qualitative Study

https://doi.org/10.1016/j.amepre.2006.12.008Get rights and content

Background

The problem of obesity is now epidemic in the United States. Despite the existence of clinical guidelines for prevention and treatment of obesity and documented clinician concern about this problem, counseling for obesity reduction in primary care is infrequent. The principal aim of this study was to examine the views of clinicians on obesity counseling and to compare these views to the recommendations of leading obesity guidelines.

Methods

Twenty individual, in-depth interviews and two focus groups of clinicians serving predominantly low-income minority populations were conducted in a practice-based research network. Data were analyzed using immersion/crystallization and template approaches.

Results

Clinicians believe obesity is an important problem and report using mostly brief, targeted, low-intensity counseling in the face of limited patient motivation and lack of resources to support weight loss. They view family, cultural, social, and community factors as central to the problem of obesity, and their own efforts as generally ineffective. These clinicians similarly were unconvinced of the long-term effectiveness of any weight-loss strategies.

Conclusions

Low levels of obesity counseling in primary care may reflect clinicians’ self-assessment of their ineffectiveness in this area rather than lack of interest or knowledge. These clinicians perceive that obesity control efforts aimed at local community factors and environmental modifications are key strategies in augmenting and linking their efforts to successful outcomes.

Introduction

Obesity has reached epidemic proportions in the United States. In the past four decades, the prevalence of obesity in adults has increased from 13% to 31%,1 and in 2005 only four states had obesity prevalence rates of less than 20%.2 In the 1999–2002 period, 16% of children and teens aged 6 to 19 years were obese, more than triple the proportion seen in 1980.3 The long-term health sequelae of obesity are well known and substantial.4, 5, 6

Over the past three decades, many clinical guidelines and recommendations addressing obesity have been published in an effort to stem the rapid increases in obesity.7, 8, 9, 10, 11 Previous surveys have consistently shown that clinicians believe obesity prevention and treatment is an important topic and that they have an important role to play.12, 13, 14, 15, 16 Yet, despite the existence of these clinical guidelines and the expressed views of clinicians about the importance of obesity, only 42% of obese adults report that healthcare professionals have advised them to lose weight, and for those whose obesity is identified, many are not treated or referred.17, 18, 19 This apparent poor impact of obesity guidelines on clinician behavior raises questions about the context in which those guidelines are applied.

Earlier survey research has suggested that barriers to delivery of obesity counseling by clinicians include lack of time, inadequate teaching materials, inadequate reimbursement, and lack of training.13, 14, 20, 21, 22, 23, 24 However, the insights provided by these studies are limited by the use of survey methods. As the prevalence of obesity continues to increase, so does the need to more fully understand the factors influencing counseling to prevent and treat obesity in primary care settings.

In an earlier publication, we reported results from this mixed methods study on factors that influence a clinician’s decision to take time to provide obesity counseling in the face of multiple competing demands within the brief primary care encounter. Stable foundational factors, such as the clinician’s life values and definitions of success were described, as well as more dynamic situational factors, including the patient’s visit agenda and the number of patients waiting to be seen.25 In this paper, primary care clinicians’ perspectives of the broader context driving their obesity counseling practices are explored using in-depth qualitative methods and compared with the recommendations of leading national obesity guidelines.

Section snippets

Study Design

The study was carried out using in-depth interviews and focus groups to investigate clinicians’ descriptions of their approaches to and broader views about counseling for prevention and treatment of obesity. The study protocol was reviewed and approved by four institutional review boards. The interviews and data analyses were conducted from January 2003 to August 2004.

Study Setting

The study was conducted in RIOS Net (Research in Outpatient Settings Network), a practice-based research network of over 250

Results

Data saturation was reached after 20 key informant interviews. Ten more RIOS Net clinicians participated in the two focus groups (seven in one group, three in the second) to confirm and refine interpretations. Among these 30 clinicians were 10 family physicians, seven pediatricians, four internists, and nine mid-level practitioners (Table 1). These clinicians had 1 to 25 years of practice experience.

Consistent with findings in other studies, these primary care clinicians believed that obesity

Discussion

We observed some important differences between clinicians’ views of obesity counseling and the recommendations of national obesity guidelines that may contribute to understanding low levels of obesity screening and counseling in primary care. Clinicians reported a targeted approach to screening and counseling, a lack of resources to assist patients with weight loss, and a dominant role of family, community, cultural, and social factors in the problem of obesity. These clinicians also emphasized

Conclusion

We observed an interesting lack of fit among the recommendations of three leading national obesity guidelines and the experiences of primary care clinicians in this study. Despite the rigorous development of these guidelines and their apparent practical design, they do not appear to be applicable in these clinicians’ practices. These findings suggest that observed low levels of attention to the problem of obesity in primary care may be based on appropriate self-assessment by clinicians of the

References (39)

  • C.L. Ogden et al.

    Prevalence and trends in overweight among U.S. children and adolescents, 1999–2000

    JAMA

    (2002)
  • E.E. Calle et al.

    Overweight, obesity, and mortality from cancer in a prospectively studied cohort of U.S. adults

    N Engl J Med

    (2003)
  • A.H. Mokdad et al.

    Prevalence of obesity, diabetes, and obesity-related health risk factors, 2001

    JAMA

    (2003)
  • M.C. Hochberg et al.

    The association of body weight, body fatness and body fat distribution with osteoarthritis of the knee: data from the Baltimore longitudinal study of aging

    J Rheumatol

    (1995)
  • Screening for obesity in adults: recommendations and rationale

    Ann Intern Med

    (2003)
  • Prevention of pediatric overweight and obesity

    Pediatrics

    (2003)
  • S.R. Daniels et al.

    Overweight in children and adolescents: pathophysiology, consequences, prevention, and treatment

    Circulation

    (2005)
  • K. Campbell et al.

    Obesity management: Australian general practitioners’ attitudes and practices

    Obes Res

    (2000)
  • Cited by (75)

    • An Integrative Approach to Obesity

      2018, Integrative Medicine: Fourth Edition
    • Physicians’ views and experiences of discussing weight management within routine clinical consultations: A thematic synthesis

      2017, Patient Education and Counseling
      Citation Excerpt :

      Thus as obesity levels rise, physicians still report significant barriers to weight management with some research suggesting decreasing levels of weight loss advice [37]. There is therefore a pressing need to gain a deeper understanding of the factors influencing weight management counselling during clinical consultations [38,39]. A recent review and meta-synthesis focused on the quantitative literature about communication about weight management [118].

    View all citing articles on Scopus
    View full text