Trends and disparities in the prevalence of physicians' counseling on diet and nutrition among the U.S. adult population, 2000-2011

From Clinic to Kitchen to Electronic Health Record: The Background and Process of Building a Culinary Medicine eConsult Service

Diet plays a pivotal role in health outcomes, influencing various metabolic pathways and accounting for over 20% of risk-attributable disability adjusted life years (DALYs). However, the limited time during primary care visits often hinders comprehensive guidance on dietary and lifestyle modifications. This paper explores the integration of electronic consultations (eConsults) in Culinary Medicine (CM) as a solution to bridge this gap. CM specialists, with expertise in the intricate connections between food, metabolism, and health outcomes, offer tailored dietary recommendations through asynchronous communication within the electronic health record (EHR) system. The use of CM eConsults enhances physician-patient communication and fosters continuous medical education for requesting clinicians. The benefits extend directly to patients, providing access to evidence-based nutritional information to address comorbidities and improve overall health through patient empowerment. We present a comprehensive guide for CM specialist physicians to incorporate CM eConsults into their practices, covering the historical context of eConsults, their adaptation for CM, billing methods, and insights from the implementation at UT Southwestern Medical Center. This initiative delivers expanded access to patient education on dietary risks and promotes interprofessional collaboration to empower improved health.

Primary Care Clinic Approaches to Facilitating Patient Health Behavior Change in Alabama

Background  Non-communicable chronic diseases (NCCDs), such as cardiovascular disease, diabetes, and cancer, are the leading cause of death and disability and the leading driver of healthcare costs in the U.S. It is estimated that 80% of chronic diseases and premature deaths are attributable to modifiable lifestyle factors related to smoking and alcohol intake, poor eating patterns, and physical inactivity. Inadequate sleep also plays a significant role. Among other directives, primary care providers (PCPs) have the opportunity to contribute to preventing and treating NCCD in their patients. Comprehensive, evidence-based behavioral counseling interventions are recommended to PCPs as a first-line approach to improving outcomes. However, presumably due to a lack of PCP time, training or resources, most patients report not receiving such services. Currently, the extent to which PCPs in Alabama offer or refer patients to health behavior change (HBC) services is unknown.  Objectives  This study aims to assess the following: (1) Alabama PCPs' current approaches in facilitating patient HBC in the domains of eating patterns, physical activity, sleep, and stress and (2) the likelihood of the Alabama PCPs referring patients to virtual HBC programs, once developed by an osteopathic medical school in the state.  Methods  Data were collected from clinic personnel who were knowledgeable regarding the clinic's approach to facilitating patient HBC via scripted telephone interviews and online surveys sent via email. The clinic list utilized for the study was derived from a list of VCOM-Auburn clinical preceptors. Primary care and specialty clinics were included. Data were analyzed descriptively to determine the number of clinics that (1) provide, recommend, or refer programs, services, or resources to patients to facilitate HBC related to eating patterns, physical activity, sleep, and stress management and (2) are likely to refer patients to free virtual HBC programs, once developed by an osteopathic medical school in the state. Results  Of the 198 clinics that were contacted, 75 were excluded, 46 were "no response," 53 agreed to participate, and 50 completed the survey. Of the 50 clinics that completed the survey, 33 indicated offering resources or referrals for diet, 29 stated they offered resources or referral services for physical activity, 33 indicated offering resources or referrals for sleep, and 28 indicated offering or recommending resources for stress management to patients. Most of the clinics (29/50) felt that their patients would benefit most from a program that facilitates improvement in eating patterns, and 41/50 clinics said that they are either "somewhat" or "extremely" likely to refer patients to a free VCOM-Auburn HBC program, once available.  Conclusions Findings indicate that a significant percentage of PCP clinics are not offering HBC resources to patients and that most PCP clinics would consider referring patients to free VCOM-Auburn HBC programs, once available. Phone data were significantly different from email data. The primary limitations were a low response rate and potential response bias.

"Food Is Medicine" Strategies for Nutrition Security and Cardiometabolic Health Equity: JACC State-of-the-Art Review

"Food Is Medicine" (FIM) represents a spectrum of food-based interventions integrated into health care for patients with specific health conditions and often social needs. Programs include medically tailored meals, groceries, and produce prescriptions, with varying levels of nutrition and culinary education. Supportive advances include expanded care pathways and payment models, e-screening for food and nutrition security, and curricular and accreditation requirements for medical nutrition education. Evidence supports positive effects of FIM on food insecurity, diet quality, glucose control, hypertension, body weight, disease self-management, self-perceived physical and mental health, and cost-effectiveness or cost savings. However, most studies to date are quasiexperimental or pre/post interventions; larger randomized trials are ongoing. New national and local programs and policies are rapidly accelerating FIM within health care. Remaining research gaps require rigorous, iterative evaluation. Successful incorporation of FIM into health care will require multiparty partnerships to assess, optimize, and scale these promising treatments to advance health and health equity.

Is It Time to Say Goodbye to BMI? A Commentary

The linkage between weight and health is complicated and our current body of evidence is inconsistent. We cannot have a discussion about weight without understanding the larger context of our antifat society and the influence of the diet industrial complex. Weight bias and a focus on weight in health care produce known harms. Additionally, clinicians often recommend losing weight without a nuanced discussion of the evidence showing that most people are unlikely to be successful with sustained weight loss. In this piece, I argue that using our precious time with patients and health care dollars to focus on health behaviors with indisputable evidence such as increasing physical activity and promoting smoking cessation is a more effective use of resources and more closely aligns with our ethical obligation to "do no harm."

Validation of the Rapid Prime Diet Quality Score Screener (rPDQS), A Brief Dietary Assessment Tool With Simple Traffic Light Scoring

BACKGROUND

Dietary pattern is a determinant of chronic disease, but nonregistered dietitian nutritionist (non-RDN) clinicians rarely assess diet because of barriers such as time constraints and lack of valid, brief diet quality assessment tools.

OBJECTIVE

The study aimed to evaluate the relative validity of a brief diet quality screener using both a numeric scoring system and a simple traffic light scoring system.

DESIGN

A cross-sectional study was conducted using the CloudResearch online platform to compare participants' responses to the 13-item rapid Prime Diet Quality Score screener (rPDQS) and the Automated Self-Administered 24-hour (ASA24) Dietary Assessment Tool.

PARTICIPANTS/SETTING

The study was conducted in July and August 2021 and included 482 adults ≥18 years of age or older sampled to be representative of the US population.

MAIN OUTCOME MEASURES

All participants completed the rPDQS and an ASA24; of these, 190 completed a second ASA24 and rPDQS. Responses to rPDQS items were coded using both traffic light (eg, green = healthiest intake, red = least healthy intake) and numeric (eg, consume < 1 time a week, consume ≥ 2 times per day) scoring methods and were compared with food group equivalents and Healthy Eating Index-2015 (HEI-2015) scores estimated from ASA24s.

STATISTICAL ANALYSES

Deattenuated Pearson correlation coefficients were calculated to account for within-person variation in 24-hour diet recalls.

RESULTS

Overall, 49% of participants were female, 62% were ≥35 years, and 66% were non-Hispanic White, 13% non-Hispanic Black, 16% Hispanic/Latino, and 5% Asian. For both food groups to encourage (eg, vegetables, whole grains) and to consume in moderation (eg, processed meats, sweets), there were statistically significant associations with intakes assessed by rPDQS, using both traffic light and numeric scoring methods. Total rPDQS scores correlated with the HEI-2015, r = 0.75 (95% confidence interval [CI] = 0.65, 0.82).

CONCLUSIONS

The rPDQS is a valid, brief diet quality screener that identifies clinically relevant patterns of food intake. Future research is needed to test whether the simple traffic light scoring system is an effective tool that can help non-RDN clinicians provide brief dietary counseling or make referrals to registered dietitian nutritionists, as needed.

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.

Impact of Culinary Medicine Course on Confidence and Competence in Diet and Lifestyle Counseling, Interprofessional Communication, and Health Behaviors and Advocacy

Most physicians report inadequate training to provide diet and lifestyle counseling to patients despite its importance to chronic disease prevention and management. To fill the nutrition training gap, elective Culinary Medicine (CM) courses have emerged as an alternative to curriculum reform. We evaluated the impact of an interprofessional CM course for medical and health professional students who experienced the hands-on cooking component in person or a in mixed-mode format (in-person and via Zoom) at the University of Utah from 2019-2023 (n = 84). A factorial ANOVA assessed differences between educational environment and changes between pre- and post-course survey responses related to diet and lifestyle counseling, interprofessional communication, and health behaviors and advocacy. Qualitative comments from post-course surveys were analyzed on a thematic level. Students rated themselves as having greater confidence and competence in diet and lifestyle counseling (p < 0.05) and increased ability to prepare eight healthy meals (p < 0.05). Additionally, a Mann-Whitney two-sample rank-sum test was used to compare data from exit survey responses from medical students who took the CM course (n = 48) and did not take the CM course (n = 297). Medical students who took CM were significantly more likely to agree that they could counsel patients about nutrition (p < 0.05) and physical activity (p < 0.05). CM courses may improve students' confidence to provide diet and lifestyle counseling.

Does Healthcare Provider Counseling for Weight Management Behaviors among Hispanic Adults Who Are Overweight/Obese Vary by Acculturation Level?

This cross-sectional study explored differences in the receipt of health care provider (HCP) counseling to control/lose weight and adopt weight-related lifestyle behavior changes among Hispanic respondents according to acculturation level. Differences in reported action regarding HCP counseling were also examined. Data from four National Health and Nutrition Examination Survey (NHANES) cycles (2011-2018) were analyzed, with the analytic sample limited to Hispanic respondents who were overweight/obese. Respondents' acculturation levels were derived from their reported country of origin and the primary language spoken at home. Respondents who reported speaking only Spanish or more Spanish than English at home were classified as primarily speaking Spanish at home. In contrast, those who reported speaking Spanish and English equally, more English than Spanish, or only English were categorized as primarily speaking English at home. Weighted multivariate logistic regression models were utilized to calculate adjusted odds ratios (ORs) and 95% confidence intervals (CIs) to determine if differences in acculturation levels existed regarding the likelihood of receiving HCP counseling to (1) control/lose weight, (2) increase exercise/PA, and (3) reduce fat/calorie intake. Similar analyses examined differences in reported action regarding HCP counseling according to acculturation level. The analysis found no significant differences in receiving HCP counseling according to acculturation level. However, non-US-born respondents who primarily spoke Spanish at home were less likely than US-born respondents to report acting to control/lose weight (p = 0.009) or increase exercise/PA (p = 0.048), but were more likely to report having taken action to reduce fat/calorie intake (p = 0.016). This study revealed differences between acting on recommendations of health care professionals according to acculturation level, indicating a need for interventions tailored to acculturation levels.

Nutritional Knowledge, Confidence, Attitudes towards Nutritional Care and Nutrition Counselling Practice among General Practitioners

Nutritional care represents any practice provided by a health professional, aimed to improve the patient's health outcomes by influencing patient's dietary habits. Clearly, dietitians are the ones supposed to provide top-quality nutrition care, but their services are often inaccessible to many for various reasons. This obliges general practitioners (GPs) in primary health care to provide nutritional counselling to their patients to a certain extent. Preconditions to successful nutritional counselling are GPs with adequate nutritional knowledge, positive attitudes towards nutrition and nutritional care, self-confident and competent in nutritional counselling. Therefore, the aim of this review is to summarise currently available information on nutritional knowledge, confidence and attitudes towards nutritional care and nutrition counselling practice of GPs, as well as barriers towards provision of nutritional counselling. GPs do not consistently obtain satisfying results in nutrition knowledge assessments and their self-confidence in nutrition counselling skills varies. Studies suggest that nutritional counselling practice still has not met its full potential, and GPs frequently report various barriers that impair nutritional counselling practice. Thus, health policies that help overcome barriers and create stimulating environment for GPs to implement nutrition counselling strategies efficiently are the key to improving quality and quantity of nutritional counselling.

Empowering learners to provide dietary counselling

BACKGROUND

Despite calls to increase dietary counselling by physicians to help address the epidemic of lifestyle-related chronic disease, medical education does not equip future physicians with the training to provide effective dietary counselling. In addition to the multiple barriers that clinician educators face in implementing clinically relevant nutrition education curricula, evaluation modalities in the nutrition education literature that assess student skills and behaviour remain limited.

APPROACH

We implemented a brief, virtual nutrition education intervention in a US medical school during the outpatient clinical clerkship and assessed how our curriculum influenced students' development of dietary counselling skills.

EVALUATION

Student feedback revealed appreciation for learning how to approach conversations about diet in a non-judgmental manner and specific strategies to use during counselling. We thematically analysed the free-text responses from 81 dietary counselling encounter forms submitted by students. Three emergent themes reflected the key dietary counselling skills students demonstrated during patient encounters: (1) eliciting drivers of current eating patterns and barriers to healthier eating patterns, (2) individualising recommendations and (3) recommending evidence-based strategies.

IMPLICATIONS

After receiving brief, clinically relevant, virtual nutrition education, students were able to successfully apply dietary counselling skills to patient care. In conjunction with indirect skill assessment through targeted documentation, we offer a sustainable approach for feasible nutrition education paired with meaningful evaluation.

Perceived intrinsic, social, and environmental barriers for weight management in older Hispanic/Latino adults with obesity

Background

The burden of obesity and chronic disease is increasing in the older US Hispanic/Latino adult population. There is limited evidence on successful weight management strategies as perceived by this population. Assessing barriers and opportunities for weight management using mixed methods is a robust approach to collect in-depth information that can be applied to the development of well-tailored weight management interventions for this population.

Objective

The objective of this study was to assess perceived individual, interpersonal, and environmental factors that influence weight management in older Hispanic/Latino adults.

Methods

This community-based cross-sectional study included 23 Hispanic/Latino older (>50y) adults with obesity (BMI >30 kg/m²). Perceived barriers and opportunities for weight management were assessed through validated questionnaires and focus groups. Prospectively registered on ClinicalTrials.gov (NCT03978416) on 7 June 2019.

Results

In this demographically heterogeneous population, language acculturation was generally low, and the frequency of poor dietary behaviors was high. Participants linked financial strain to lower diet quality, as well as anxiety to uncontrolled eating and food cravings. Social support and trust in healthcare professionals were perceived as priorities for healthy eating. Structural and environmental barriers such as affordability and availability of culturally preferred foods were also identified as influences on food choices and eating behavior.

Conclusions

This study revealed opportunities for culturally tailored weight management interventions in older Hispanic/Latino adults with obesity.

Clinical Trial Registry Number

NCT03978416 (ClinicalTrials.gov).

Health Behavior Change Programs in Primary Care and Community Practices for Cardiovascular Disease Prevention and Risk Factor Management Among Midlife and Older Adults: A Scientific Statement From the American Heart Association

Cardiovascular disease predominates as the leading health burden among middle-aged and older American adults, but progress in improving cardiovascular health remains slow. Comprehensive, evidenced-based behavioral counseling interventions in primary care are a recommended first-line approach for promoting healthy behaviors and preventing poor cardiovascular disease outcomes in adults with cardiovascular risk factors. Assisting patients to adopt and achieve their health promotion goals and arranging follow-up support are critical tenets of the 5A Model for behavior counseling in primary care. These 2 steps in behavior counseling are considered essential to effectively promote meaningful and lasting behavior change for primary cardiovascular disease prevention. However, adoption and implementation of behavioral counseling interventions in clinical settings can be challenging. The purpose of this scientific statement from the American Heart Association is to guide primary health care professional efforts to offer or refer patients for behavioral counseling, beyond what can be done during brief and infrequent office visits. This scientific statement presents evidence of effective behavioral intervention programs that are feasible for adoption in primary care settings for cardiovascular disease prevention and risk management in middle-aged and older adults. Furthermore, examples are provided of resources available to facilitate the widespread adoption and implementation of behavioral intervention programs in primary care or community-based settings and practical approaches to appropriately engage and refer patients to these programs. In addition, current national models that influence translation of evidence-based behavioral counseling in primary care and community settings are described. Finally, this scientific statement highlights opportunities to enhance the delivery of equitable and preventive care that prioritizes effective behavioral counseling of patients with varying levels of cardiovascular disease risk.

Teaching Medical Students to Help Patients Manage Their Weight: Outcomes of an Eight-School Randomized Controlled Trial

BACKGROUND

Given the rising rates of obesity there is a pressing need for medical schools to better prepare students for intervening with patients who have overweight or obesity and for prevention efforts.

OBJECTIVE

To assess the effect of a multi-modal weight management curriculum on counseling skills for health behavior change.

DESIGN

A pair-matched, group-randomized controlled trial (2015-2020) included students enrolled in eight U.S. medical schools randomized to receive either multi-modal weight management education (MME) or traditional weight management education (TE).

SETTING/PARTICIPANTS

Students from the class of 2020 (N=1305) were asked to participate in an objective structured clinical examination (OSCE) focused on weight management counseling and complete pre and post surveys. A total of 70.1% of eligible students (N=915) completed the OSCE and 69.3% (N=904) completed both surveys.

INTERVENTIONS

The MME implemented over three years included a web-based course, a role-play classroom exercise, a web-patient encounter with feedback, and an enhanced clerkship experience with preceptors trained in weight management counseling (WMC). Counseling focused on the 5As (Ask, Advise, Assess, Assist, Arrange) and patient-centeredness.

MEASUREMENTS

The outcome was student 5As WMC skills assessed using an objective measure, an OSCE, scored using a behavior checklist, and a subjective measure, student self-reported skills for performing the 5As.

RESULTS

Among MME students who completed two of three WMC components compared to those who completed none, exposure was significantly associated with higher OSCE scores and self-reported 5A skills.

LIMITATIONS

Variability in medical schools requiring participation in the WMC curriculum.

CONCLUSIONS

This trial revealed that medical students struggle with delivering weight management counseling to their patients who have overweight or obesity. Medical schools, though restrained in adding curricula, should incorporate should incorporate multiple WMC curricula components early in medical student education to provide knowledge and build confidence for supporting patients in developing individualized plans for weight management.

NIH TRIAL REGISTRY NUMBER

R01-194787.

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.

Nutrition Education in Primary Care Adult and Family Nurse Practitioner Programs

BACKGROUND

Educating and training clinicians to deliver nutrition interventions is critical to improve population health. However, the adequacy of nutrition education within primary care adult and family nurse practitioner (ANP/FNP) curricula has not been addressed.

PURPOSE

The purpose of this study was to describe faculty perceptions of nutrition education in ANP/FNP programs.

METHODS

We used a cross-sectional design to gather data on nutrition education. The survey was administered to a convenience sample of faculty from the United States.

RESULTS

Our response rate was 47.8% (N = 49). The mean ± SD hours of nutrition education was 14.4 ± 14.6. One-fourth of schools reported that their students received at least 25 hours of nutrition education. Most participants thought it was very or extremely important (75.6%) that their students become more educated about nutrition.

CONCLUSIONS

There is a need and desire for more nutrition education within nursing graduate curricula. Novel strategies to implement nutrition education in nurse practitioner curriculum are needed.

Exposure to Weight Management Counseling Among Students at 8 U.S. Medical Schools

INTRODUCTION

Clinical guidelines support physician intervention consistent with the Ask, Advise, Assess, Assist, Arrange framework for adults who have obesity. However, weight management counseling curricula vary across medical schools. It is unknown how frequently students receive experiences in weight management counseling, such as instruction, observation, and direct experience.

METHODS

A cross-sectional survey, conducted in 2017, of 730 third-year medical students in 8 U.S. medical schools assessed the frequency of direct patient, observational, and instructional weight management counseling experiences that were reported as summed scores with a range of 0‒18. Analysis was completed in 2017.

RESULTS

Students reported the least experience with receiving instruction (6.5, SD=3.9), followed by direct patient experience (8.6, SD=4.8) and observational experiences (10.3, SD=5.0). During the preclinical years, 79% of students reported a total of ≤3 hours of combined weight management counseling instruction in the classroom, clinic, doctor's office, or hospital. The majority of the students (59%-76%) reported never receiving skills-based instruction for weight management counseling. Of the Ask, Advise, Assess, Assist, Arrange framework, scores were lowest for assisting the patient to achieve their agreed-upon goals (31%) and arranging follow-up contact (22%).

CONCLUSIONS

Overall exposure to weight management counseling was less than optimal. Medical school educators can work toward developing a more coordinated approach to weight management counseling.

Nutrition from the kitchen: culinary medicine impacts students' counseling confidence

BACKGROUND

Although a poor diet is the number one risk factor for early death in the United States and globally, physicians receive little to no training in dietary interventions and lack confidence counseling patients about lifestyle modifications. Innovative, interprofessional strategies to address these gaps include the emergence of culinary medicine, a hands-on approach to teaching the role of food in health outcomes. We sought to assess the impact of a culinary medicine elective on counseling confidence, awareness of an evidence-based approach to nutrition, and understanding of the role of interprofessional teamwork in dietary lifestyle change among medical students at one undergraduate medical school.

METHODS

We administered pre- and post-course surveys to two cohorts of medical students (n = 64 at pre-test and n = 60 at post-test) participating in a culinary medicine enrichment elective. Chi-square analysis was used to assess the relationship between participation in the course and a positive response to each survey item.

RESULTS

Compared with the baseline, students participating in culinary medicine were more likely to feel confident discussing nutrition with patients (29% vs 92%; p < 0.001), to feel familiar with the Mediterranean diet (54% vs. 97%; p < 0.001), and to understand the role of dietitians in patient care (37% vs. 93%; p < 0.001).

CONCLUSIONS

Culinary medicine shows promise as an impactful educational strategy among first-year medical students for increasing counseling confidence, promoting familiarity with evidence-based nutrition interventions, and augmenting understanding of the role of interprofessional engagement to address lifestyle-related disease.

Exercise and Diet Counseling Trends From 2002 to 2015: A Serial Cross-Sectional Study of U.S. Adults With Cardiovascular Disease Risk

INTRODUCTION

Exercise and dietary behavioral counseling are effective clinical practices recommended by the U.S. Preventive Services Task Force to reduce cardiovascular disease risk among high-risk individuals.

METHODS

Medical Expenditure Panel Survey data from 2002 to 2015 were analyzed in 2018. Prevalence ratios of exercise, dietary, and both types of counseling among individuals with overweight or obesity with additional cardiovascular disease risk factors were calculated and adjusted for demographic covariates (N=116,048). Adjusted prevalence ratios were calculated for sociodemographic and health factors associated with counseling receipt using 2014-2015 data.

RESULTS

From 2002 to 2015, adjusted prevalence ratios ranged from 43% to 63%. Compared with 2002, receipt of both types of counseling was 6% higher in 2015 (49%, 95% CI=48%, 51%). In 2015, compared with privately insured people, those without insurance (prevalence ratio=0.91, 95% CI=0.84, 0.99) or on Medicare (prevalence ratio=0.77, 95% CI=0.73, 0.82) were less likely to receive counseling. Individuals with 3 (prevalence ratio=1.46, 95% CI=1.39, 1.54), 4 (prevalence ratio=1.74, 95% CI=1.63, 1.85), or 5 (prevalence ratio=1.89, 95% CI=1.67, 2.15) cardiovascular disease risk factors received counseling more frequently than those with 2 cardiovascular disease risk factors. Female participants (prevalence ratio=1.07, 95% CI=1.03, 1.11) and racial minorities (Hispanics: prevalence ratio=1.31, 95% CI=1.24, 1.38; Blacks: prevalence ratio=1.11, 95% CI=1.05, 1.18; Asians: prevalence ratio=1.12, 95% CI=1.01, 1.24) reported higher rates of counseling.

CONCLUSIONS

Despite modest improvements since 2002, up to 37% of individuals at high cardiovascular disease risk were not receiving exercise counseling, and 43% were not receiving dietary counseling in 2015. Continued implementation and scale up of effective programs to increase behavioral lifestyle counseling among high-risk populations are needed more than ever to mitigate the U.S. cardiometabolic disease burden.

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.

Provider Advice and Patient Perceptions on Weight Across Five Health Systems

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Rapid Diet Assessment Screening Tools for Cardiovascular Disease Risk Reduction Across Healthcare Settings: A Scientific Statement From the American Heart Association

It is critical that diet quality be assessed and discussed at the point of care with clinicians and other members of the healthcare team to reduce the incidence and improve the management of diet-related chronic disease, especially cardiovascular disease. Dietary screening or counseling is not usually a component of routine medical visits. Moreover, numerous barriers exist to the implementation of screening and counseling, including lack of training and knowledge, lack of time, sense of futility, lack of reimbursement, competing demands during the visit, and absence of validated rapid diet screener tools with coupled clinical decision support to identify actionable modifications for improvement. With more widespread use of electronic health records, there is an enormous unmet opportunity to provide evidence-based clinician-delivered dietary guidance using rapid diet screener tools that must be addressed. In this scientific statement from the American Heart Association, we provide rationale for the widespread adoption of rapid diet screener tools in primary care and relevant specialty care prevention settings, discuss the theory- and practice-based criteria of a rapid diet screener tool that supports valid and feasible diet assessment and counseling in clinical settings, review existing tools, and discuss opportunities and challenges for integrating a rapid diet screener tool into clinician workflows through the electronic health record.

Racial/ethnic variations in weight management among patients with overweight and obesity status who are served by health centres

This study sought to examine racial/ethnic variations in receipt of provider recommendations on weight loss, patient adherence, perception of weight, attempts at weight loss and actual weight loss among patients with overweight/obesity status at Health Resources and Services Administration-funded health centres (HC). We used a 2014 nationally representative survey of adult HC patients with overweight/obesity status (PwOW/OB) last year and reported the HC was their usual source of care (n = 3517). We used logistic regression models to assess the interaction of race/ethnicity and having obesity in (1) provider recommendations of diet or (2) exercise, (3) patient adherence to diet or (4) exercise, (5) perceptions of weight and (6) weight loss attempts. We used a multinomial regression model to examine (7) weight loss or gain vs no change and a linear regression model to evaluate (8) percent weight change. We found Black PwOW/OB (OR = 1.65) experienced greater odds of receiving diet recommendations than Whites. We found limited racial/ethnic disparities in adherence. Black (OR = 0.41), Hispanic/Latino (OR = 0.45), and American Indian/Alaska Native (OR = 0.41) PwOW/OB had lower odds of perceiving themselves as overweight. Black (OR = 1.68) and Hispanic (OR = 1.98) PwOW/OB had a greater odds of reporting weight gain, and Asian PwOW/OB (OR = 0.42) had lower odds of reporting weight loss than Whites. Disparities in provider diet recommendations among Blacks and Hispanics indicated the importance of personalized weight management recommendations. Understanding underlying reasons for discordance between self-perception and observed weight among different groups is needed. Overall increase in weight, despite current interventions, should be addressed through targeted racially/ethnically appropriate approaches.

Progress in Cancer Control in Maryland: 1985-2015

PURPOSE

Maryland historically had a high cancer burden, which prompted the implementation of aggressive cancer control strategies. We examined the status of cancer in Maryland and work under the current and previous editions of the MD Comprehensive Cancer Control Plan.

METHODS

We examined the prevalence of cancer mortality, cancer incidence, and cancer-related behaviors in Maryland and the United States from 1985 to 2015 using publicly available data in the US Cancer Control PLANET, CDC WONDER, and Behavioral Risk Factor Surveillance System portals. We estimated the average annual cancer deaths avoided by triangulation.

RESULTS

In 1983-1987, Maryland had the highest age-adjusted cancer mortality rate of all 50 states, second only to Washington, District of Columbia. Today (2011-2015), Maryland's age-adjusted cancer mortality rate ranks 31st. Overall cancer mortality rates have declined 1.9% annually from 1990 to 2015, avoiding nearly 60 000 deaths over 3 decades. While the prevalence of healthy cancer-related behaviors in Maryland was qualitatively similar or higher than that of the United States in 2015, Maryland's 5-year (2011-2015) cancer incidence rate was significantly greater than that of the United States.

CONCLUSIONS

Maryland's 30-year cancer mortality declines have outpaced other states. However, a reduction in mortality while incidence rates remain high indicates a need for enhanced focus on primary prevention.

Behavioral Counseling Training for Primary Care Providers: Immersive Virtual Simulation as a Training Tool

Behavioral counseling represents an efficacious approach for improving health behaviors on a population level, and the primary care setting is an appropriate context in which to implement this approach. However, evidence suggests that the utilization of behavioral counseling techniques in primary care, including those informed by motivational interviewing, is sub-optimal. Insufficient training has been cited as a barrier to utilizing counseling in the primary care setting. Recent work has evaluated the effectiveness of virtual simulations that can provide access to "virtual" patients while retaining the scalability inherent to a digital medium. However, these educational interventions have been limited to simulations delivered through a two-dimensional screen. More immersive simulations delivered through a head-mounted display can create a realistic practice environment that encompasses a learner's entire field of view, which may confer additional benefits with respect to training outcomes. The purpose of this short article is to briefly review the relevant literature across disciplines to conceptualize the potential effectiveness of this technology as a training tool for behavioral counseling. Immersive virtual simulations are designed to induce a psychological phenomenon referred to as presence, whereby a learner perceives themselves as existing within the virtual environment. As such, immersive virtual simulations can provide opportunities for practice, coaching, and feedback in an environment that closely approximates the clinical setting in which counseling will be delivered. Through its effects on presence, this technology may be particularly useful for developing empathy, which is an important component of counseling. Recommendations for future research are also provided.

Women's recall of health care provider counselling on gestational weight gain (GWG): a prospective, population-based study

BACKGROUND

Prenatal care has been validated to provide medical and educational counselling intended to reduce the risk of adverse pregnancy conditions and improve the maternal and fetal outcomes. Prenatal targeted information regarding nutrition, lifestyle, and weight gain is predictive of meeting Institute of Medicine (IOM) 2009 gestational weight gain (GWG) guidelines. There is limited information about women's experiences with these prenatal counselling domains, particularly in women who do not meet GWG recommendations. The objective of this study was to evaluate the impact of women's recall of prenatal counselling and its effect on meeting their GWG within guidelines in a prospective, community-based pregnancy cohort.

METHODS

A sample of 2909 women with singleton pregnancies was drawn from the prospective community-based pregnancy cohort All Our Families from Alberta, Canada. Women were stratified into three GWG groups, adequate, inadequate, and excessive GWG, based on pre-pregnancy BMI and the adherence to the Institute of Medicine weight gain in pregnancy guidelines. At less than 25 and 34 to 36 weeks' gestation, maternal socio-demographic information and women's recall of prenatal counselling experiences was collected through self-administered questionnaires. Multivariate logistic regression analyses tested GWG strata impact on women's recall of the prenatal counselling advice in eight domains of nutrition, lifestyle, and weight management during pregnancy.

RESULTS

Adequate GWG was reached by 35.9% of women, 46.5% gained excessive and 17.6% gained inadequate weight. Women who were overweight and obese prior to pregnancy were more likely to gain excessive weight than women who were normal weight (OR 3.3, 95% CI 2.6-4.1; and OR 2.9, 95% CI 2.1-3.9, respectively). Most women reported having no difficulties in finding prenatal care, felt comfortable with their health care provider and were satisfied with the answers received. There was no difference in the recall of prenatal advice received in any of the eight domains of prenatal counselling assessed among women with appropriate and non-optimal GWG.

CONCLUSION

Women with adequate and non-optimal GWG received comparable prenatal counselling on nutrition, weight gain, and lifestyle modifications. There remain missed opportunities in targeting prenatal counselling advice to women at risk for suboptimal or excessive GWG.

Medical Nutrition Education, Training, and Competencies to Advance Guideline-Based Diet Counseling by Physicians: A Science Advisory From the American Heart Association

Growing scientific evidence of the benefits of heart-healthy dietary patterns and of the massive public health and economic burdens attributed to obesity and poor diet quality have triggered national calls to increase diet counseling in outpatients with atherosclerotic cardiovascular disease or risk factors. However, despite evidence that physicians are willing to undertake this task and are viewed as credible sources of diet information, they engage patients in diet counseling at less than desirable rates and cite insufficient knowledge and training as barriers. These data align with evidence of large and persistent gaps in medical nutrition education and training in the United States. Now, major reforms in undergraduate and graduate medical education designed to incorporate advances in the science of learning and to better prepare physicians for 21st century healthcare delivery are providing a new impetus and novel ways to expand medical nutrition education and training. This science advisory reviews gaps in undergraduate and graduate medical education in nutrition in the United States, summarizes reforms that support and facilitate more robust nutrition education and training, and outlines new opportunities for accomplishing this goal via multidimensional curricula, pedagogies, technologies, and competency-based assessments. Real-world examples of efforts to improve undergraduate and graduate medical education in nutrition by integrating formal learning with practical, experiential, inquiry-driven, interprofessional, and population health management activities are provided. The authors conclude that enhancing physician education and training in nutrition, as well as increasing collaborative nutrition care delivery by 21st century health systems, will reduce the health and economic burdens from atherosclerotic cardiovascular disease to a degree not previously realized.

"Take Me through the History of Your Weight": Using Qualitative Interviews to Create Personalized Weight Trajectories to Understand the Development of Obesity in Patients Preparing for Bariatric Surgery

BACKGROUND

Obesity can develop during any life stage. Understanding the contexts within which obesity develops can inform our understanding of the disease and help tailor interventions specific to life stages.

OBJECTIVE

Using life-course theory as a guiding framework, this study aimed to explain the development of obesity in bariatric surgery patients by creating personalized weight trajectories.

DESIGN

Qualitative methods using semistructured interviews were used to uncover participants' experiences with and explanations for the development of obesity. A grounded theory approach using the constant comparative method was used to analyze transcripts for categories and themes.

PARTICIPANTS/SETTING

Thirty pre-bariatric surgery patients (24 women, 6 men) were recruited from a bariatric surgery center; 25 participants were available for follow-up. Participants were interviewed before surgery and at 6 and 12 months postsurgery.

RESULTS

Four weight history groups were created based on patterns of weight changes from adolescence through adulthood: Always Heavy, Late Peak, Steady Progression, and Weight Cycling. Participants' explanations for weight changes centered around themes of transitions and life-course events or stressors. Differences in the weight history groups could be explained by the timing of transitions, life events, and responses to stress.

CONCLUSIONS

The development of obesity does not follow the same pattern for all individuals. Weight gain patterns can be explained by the timing of life-course events, stressors, and the type and effects of environmental transitions. Weight management counseling should include strategies tailored to an individual's current life-stage and circumstance, but also acknowledge previous responses to transitions and stressors.

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.

Adult obesity management in primary care, 2008-2013

In the U.S., the occurrence of weight counseling in primary care for patients with obesity decreased by 10% between 1995-1996 and 2007-2008. There have been several national recommendations and policies to improve obesity management since 2008. The purpose of this study was to examine the rates of body mass index (BMI) screening, obesity diagnosis, and weight management counseling in the U.S. from 2008 to 2013. The National Ambulatory Medical Care Survey visit-level data for adults 18 and over with a primary care visit during survey years 2008-2009, 2010-2011, and 2012-2013 was included in the analyses using SAS v9.3. Study outcomes included percent of visits with: BMI screening; obesity diagnosis; and weight counseling. We compared survey years on these outcomes using 2008-2009 as the reference as well as examined patient and practice-level predictors. Analyses were conducted from 2015 to early 2017. Of the total 55,608 adult primary care visits sampled, 14,143 visits (25%) were with patients with obesity. BMI screening significantly increased between 2008-2009 and 2012-2013 from 54% to 73% (OR=1.75, 95% CI 1.28-2.41); however, percent of visits with an obesity diagnosis remained low at <30%. Weight management counseling during visits significantly declined from 33% to 21% between 2008-2009 and 2012-2013 (OR=0.62, 95% CI 0.41-0.92). Despite emerging recommendations and policies, from 2008 to 2013, obesity management in primary care remained suboptimal. Identifying practical strategies to enforce policies and implement evidence-based behavioral treatment in primary care should be a high priority in healthcare reform.

A Quasi-Experiment to Assess the Impact of a Scalable, Community-Based Weight Loss Program: Combining Reach, Effectiveness, and Cost

BACKGROUND

Primary care addresses obesity through physician oversight of intensive lifestyle interventions or referral to external programs with demonstrated efficacy. However, limited information exists on community program reach, effectiveness, and costs across different groups of participants.

OBJECTIVE

To evaluate a scalable, community weight loss program using reach, effectiveness, and cost metrics.

DESIGN

Longitudinal pre-post quasi-experiment without control.

PARTICIPANTS

Enrolled participants in Weigh and Win (WAW), a community-based weight loss program.

INTERVENTION

A 12-month program with daily social cognitive theory-based email and/or text support, online access to health coaches, objective weight assessment through 83 community-based kiosks, and modest financial incentives to increase program reach.

MAIN MEASURES

Number of participants, representativeness, weight loss achievement (3%, 5% of initial weight lost), and cost of implementation.

KEY RESULTS

A total of 40,308 adults (79% women; 73% white; BMI = 32.3 ± 7.44, age = 43.9 ± 13.1 years) enrolled in WAW. Women were more likely than men to enroll in the program and continue engagement beyond an initial weigh-in (57% vs. 53%). Based on census data, African Americans were over-represented in the sample. Among participants who engaged in the program beyond an initial weigh-in (n = 19,029), 47% and 34% of participants lost 3% and 5% of their initial body weight, respectively. The average duration for those who achieved 5% weight loss was 1.7 ± 1.3 years. African American participants were more likely to achieve 5% weight loss and remain enrolled in the program longer compared to non-African American participants (2.0 ± 1.3 vs. 1.6 ± 1.2 years). Implementation costs were $2,822,698. Cost per clinically meaningful weight loss for African Americans ($257.97/3% loss; $335.96/5% loss) was lower than that for Hispanics ($318.62; $431.10) and Caucasians ($313.65; $441.87), due to the higher success rate of that subgroup of participants.

CONCLUSIONS

Weigh and Win is a scalable technology-supported and community-based weight loss program that reaches a large number of participants and may contribute to reducing health disparities.