Research articleObesity Counseling and Guidelines in Primary Care: A Qualitative Study
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
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