Are physicians equipped to address the obesity epidemic? Knowledge and attitudes of internal medicine residents

Utilising a modified accelerated Delphi process to develop a national multidisciplinary consensus on peri-operative optimisation of patients with obesity undergoing non-bariatric surgery

BACKGROUND

In the last three decades, the worldwide prevalence of obesity has increased by threefold. Using a modified Delphi consensus technique, the Irish Surgical Research Collaborative (ISRC) aimed to formulate consensus guidelines on the peri-operative optimisation of patients with obesity undergoing non-bariatric surgery.

METHODS

Subgroups within the ISRC were established to formulate consensus statements using a nominal group technique (NGT) to address the three domains of pre-operative, intra-operative and post-operative care. Three Delphi rounds were circulated nationally to multidisciplinary members of the peri-operative team via electronic survey. Consensus was considered achieved for any statement with >80 % agreement. Data was analysed using Microsoft Excel (Microsoft Corp, Redmond, WA).

RESULTS

Following three Delphi rounds, a total of 94 statements centred around optimising peri-operative care for patients with obesity undergoing non-bariatric surgery reached consensus. Pre-operatively, access to prehabilitation, use of pre-operative risk stratification tools and strategies to reduce obesity-related co-morbidities were all deemed important along with nomination of a hospital obesity lead. Intra-operatively, the prioritised domains were involvement of consultant anaesthetist and surgeon for safe and considered patient positioning, utilisation of minimally invasive surgical techniques, adherence to venous thromboembolism prophylaxis and surgical site infection prevention strategies as well as adoption of multimodal analgesia. Appropriate analgesia prescription, nutritional support, enhanced recovery after surgery and the role of physiotherapy were all deemed essential elements of post-operative care.

CONCLUSION

As a multidisciplinary peri-operative group, through Delphi consensus, we report agreed perioperative standards to optimise the perioperative care of patients with obesity undergoing non-bariatric surgery. This consensus can be utilised to standardise clinical practice and identify areas for quality improvement.

Leveraging diagnosis and biometric data from the All of Us Research Program to uncover disparities in obesity diagnosis

Background

Despite extensive efforts to standardize definitions of obesity, clinical practices of diagnosing obesity vary widely. This study examined (1) discrepancies between biometric body mass index (BMI) measures of obesity and documented diagnoses of obesity in patient electronic health records (EHRs) and (2) how these discrepancies vary by patient gender and race and ethnicity from an intersectional lens.

Methods

Observational study of 383,380 participants in the National Institutes of Health All of Us Research Program dataset.

Results

Over half (60 %) of participants with a BMI indicating obesity had no clinical diagnosis of obesity in their EHRs. Adjusting for BMI, comorbidities, and other covariates, women's adjusted odds of diagnosis were far higher than men's (95 % confidence interval 1.66-1.75). However, the gender gap between women's and men's likelihood of diagnosis varied widely across racial groups. Overall, Non-Hispanic (NH) Black women and Hispanic women were the most likely to be diagnosed and NH-Asian men were the least likely to be diagnosed.

Conclusion

Men, and particularly NH-Asian men, may be at heightened risk of underdiagnosis of obesity. Women, and especially Hispanic and NH-Black women, may be at heightened risk of unanticipated harms of obesity diagnosis, including stigma and competing demand with other health concerns. Leveraging diagnosis and biometric data from this unique public domain dataset from the All of Us project, this study revealed pervasive disparities in diagnostic attribution by gender, race, and ethnicity.

Opportunities for General Internal Medicine to Promote Equity in Obesity Care

The number and complexity of obesity treatments has increased rapidly in recent years. This is driven by the approval of new anti-obesity medications (AOMs) that produce larger degrees of weight loss than previously approved AOMs. Unfortunately, access to these highly effective therapies and to integrated team-based obesity care is limited by intra-/interpersonal patient, institutional/practitioner, community, and policy factors. We contextualized these complexities and the impact of patients' social drivers of health (SDOH) by adapting the social ecological model for obesity. Without multi-level intervention, these barriers to care will deepen the existing inequities in obesity prevalence and treatment outcomes among historically underserved communities. As General Internal Medicine (GIM) physicians, we can help our patients navigate the complexities of evidence-based obesity treatments. As care team leaders, GIM physicians are well-positioned to (1) improve education for trainees and practitioners, (2) address healthcare-associated weight stigma, (3) advocate for equity in treatment accessibility, and (4) coordinate interdisciplinary teams around non-traditional models of care focused on upstream (e.g., policy changes, insurance coverage, health system culture change, medical education requirements) and downstream (e.g., evidence-based weight management didactics for trainees, using non-stigmatizing language with patients, developing interdisciplinary weight management clinics) strategies to promote optimal obesity care for all patients.

Surveying the Knowledge and Practices of Primary Care Residents in Managing Adult Patients with Obesity

BACKGROUND

The prevalence of obesity is increasing worldwide at an alarming rate, yet obesity remains under-addressed during clinic encounters. A lack of training in how to treat obesity is one crucial factor contributing to this deficiency.

OBJECTIVE

This study explored resident physicians' perceptions of their education on obesity and its relationship with confidence and practice behaviors when caring for patients with obesity.

DESIGN

A survey was distributed to residency directors to share with residents in their programs. Participation was voluntary and anonymous. Data was collected over a 3-month period.

PARTICIPANTS

Residents in Family Medicine and Internal Medicine programs in West Virginia and Indiana who saw adult patients in an ambulatory care setting.

MAIN MEASURES

The electronic survey queried the presence of a formal curriculum on Obesity Medicine (OM) and each resident's knowledge, confidence, practice behaviors, and attitudes pertaining to OM.

KEY RESULTS

The survey was distributed to 490 residents in 12 programs. Response rate was 22.9% (112 resident physicians). All respondents felt that medical training in obesity should be strengthened. Residents who reported having a formal curriculum on OM were more likely than those without a curriculum to rate their confidence as "high" when discussing weight (35.0% vs. 16.7%, p = 0.03) and when counseling patients about diet and nutrition (37.5% vs. 18.1%, p = 0.02). They also more frequently reported learning enough from faculty to manage obesity (65.0% vs. 29.2%, p < 0.001). Residents with an OM curriculum reported discussing obesity as a problem with patients (100.0% vs. 86.1%, p = 0.01), and completing motivational interviews (90.0% vs. 58.3%, p =  < 0.001), more frequently than their peers without a curriculum.

CONCLUSIONS

Residents with a formal OM curriculum were more confident in addressing and discussing obesity with patients. Formal training in OM will strengthen resident training to better address and treat patients with obesity.

Medical students' perceived comfort and competence performing physical examinations on patients with obesity: A mixed-methods needs assessment

Physicians are unsatisfied with their training in the care of patients with obesity. Physical examination is a key component of care, and modifications to techniques are often necessary for patients with obesity. To determine learning needs, we examined medical students' perceived comfort and competency in conducting physical examinations on patients with obesity. This mixed-methods study of Canadian medical students used a questionnaire and semi-structured focus groups to assess medical students' perceived comfort and competence in examining patients with obesity. Participants included 175 Canadian medical students. A minority of medical students felt comfortable (42%) or competent (14%) examining patients with obesity. Physical exam challenges included modifying exam manoeuvres, interpreting findings and communicating sensitively around weight. Lack of early exposure to patients with obesity, minimal instruction by preceptors and a lack of curricular focus on obesity were felt to be barriers to improving these skills. Students perceived their lack of confidence as negatively impacting their ability to manage patients with obesity and more training in this area was desired to prevent disparities in care. Medical students feel that adequate training on how to perform an obesity-specific physical examination is lacking. Developing curricula and including formal teaching around these key competencies within medical education is essential.

Perceptions of Adult Obesity Education: A Pilot Study

Objectives

This pilot research study, conducted at a large academic healthcare facility, used mixed methodology to (1) administer a survey to a group of primary care trainees and faculty and (2) conduct key informant interviews with the program directors, or their delegates of these primary care training programs, so as to gain insight into respondents' perceptions about their training on adult obesity. To maintain confidentiality of the key informants, they were defined as "Administrators." Faculty and trainees were from family medicine and internal medicine residency programs, as well as family nurse practitioner and physician assistant training programs.

Methods

This study used a quantitative survey and four qualitative key informant (Administrator) interviews. Descriptive statistics, χ2, or Fisher exact tests were used to analyze select survey responses. Administrator interviews were analyzed with thematic analysis.

Results

Survey respondents (n = 75) included primary care trainees (n=34), faculty (n=30), other (n=2), did not answer (n=9). Surveys indicated that additional training is needed for bariatric surgery, weight loss medications, and clinical nutrition. The three highest ranked topics in the surveys on adult obesity were basic nutrition, behavioral weight management, and a rotation on adult obesity. Most agreed on the need for interprofessional collaboration, a centralized obesity treatment center, and an introductory obesity course. Key themes from the four Administrator interviews revealed the need: for more training; to build upon current curriculum; use innovative technology; fiscal challenges; and time management.

Conclusions

Both faculty and trainees perceive that academic and clinical training on adult obesity is inadequate, and that trainees need more education on such topics as nutrition, physical activity, behavioral health, antiobesity medications, and bariatric surgery. Competency to treat varied by topic. It also showed that more interprofessional collaboration and a centralized obesity treatment center are needed. Recommendations included integrating modular units about obesity into already established primary care training programs and providing additional resources.

Impact of a Teaching Kitchen Curriculum for Health Professional Trainees in Nutrition Knowledge, Confidence, and Skills to Advance Obesity Prevention and Management in Clinical Practice

Nutrition knowledge, confidence, and skills are thought to be important elements in the role of healthcare professionals in obesity prevention and management. The Upstream Obesity Solutions curriculum goes upstream with a multidisciplinary approach to supplement nutrition education among health professional trainees. Educational strategies of didactics, teaching kitchens, and service-based learning were employed for medical, dental, and nursing students and resident physicians. Pre/post participation surveys assessed knowledge, attitude, and practices; lifestyle habits; and culinary skills among 75 trainees in this cross-sectional descriptive study. There was variability in statistically significant improvement in knowledge, attitudes, and practices about obesity management and nutrition education, lifestyle habits, and culinary skills among learner groups.

We Must Address the Antiobesity Biases We Espouse in Our Operating Rooms

OBJECTIVE

To describe anti-obesity bias in medical education including impact on patients, growth of biases over time, and education-based initiatives aimed at reducing bias.

DESIGN

We reviewed available literature on anti-obesity bias in medical education and initiatives to address this bias.

SETTING

Information from a wide variety of medical educational settings was included.

PARTICIPANTS

N/A RESULTS: Anti-obesity bias in healthcare is an independent risk factor for poor health outcomes and is pervasive throughout the culture of medicine. Medical students identify operating rooms as the number one location for anti-obesity comments, and students' biases increase throughout medical school. We propose several interventions (the 6 I's) as the next step in addressing this bias.

Video-based communication assessment for weight management counseling training in medical residents: a mixed methods study

BACKGROUND

Physician delivered weight management counseling (WMC) occurs infrequently and physicians report lack of training and poor self-efficacy. The purpose of this study was to develop and test the Video-based Communication Assessment (VCA) for weight management counseling (WMC) training in medical residents.

METHODS

This study was a mixed methods pilot conducted in 3 phases. First, we created five vignettes based on our prior data and expert feedback, then administered the vignettes via the VCA to Internal Medicine categorical residents (n = 16) from a University Medical School. Analog patients rated responses and also provided comments. We created individualized feedback reports which residents were able to view on the VCA. Lastly, we conducted debriefing interviews with the residents (n = 11) to obtain their feedback on the vignettes and personalized feedback. Interviews were transcribed, and we used thematic analysis to generate and apply codes, followed by identifying themes.

RESULTS

Descriptive statistics were calculated and learning points were created for the individualized feedback reports. In VCA debriefing interviews with residents, five themes emerged: 1) Overall the VCA was easy to use, helpful and more engaging than traditional learning and assessment modes, 2) Patient scenarios were similar to those encountered in the clinic, including diversity, health literacy and different stages of change, 3) The knowledge, skills, and reminders from the VCA can be transferred to practice, 4) Feedback reports were helpful, to the point and informative, including the exemplar response of how to best respond to the scenario, and 5) The VCA provide alternatives and practice scenarios to real-life patient situations when they aren't always accessible.

CONCLUSIONS

We demonstrated the feasibility and acceptability of the VCA, a technology delivered platform, for delivering WMC to residents. The VCA exposed residents to diverse patient experiences and provided potential opportunities to tailor providers responses to sociological and cultural factors in WMC scenarios. Future work will examine the effect of the VCA on WMC in actual clinical practice.

Introducing Lifestyle Medicine Within the Mayo Clinic Alix School of Medicine in Arizona

Purpose: High-value care is becoming increasingly important as the United States shifts toward a more sustainable health care system. Lifestyle medicine (LM) may be the highest-value model of care. Surprisingly, however, it is taught in a minority of medical schools. In this article, we describe a pilot project of introducing a brief LM course taught within the Mayo Clinic Alix School of Medicine in Arizona. The main purpose of the course was to introduce the students to LM as a specialty practice and to provide students with foundational knowledge of the pillars of LM. Results: Students reported improved personal health habits and increased confidence in LM competencies.

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.

Benchmarking of provider competencies and current training for prevention and management of obesity among family medicine residency programs: a cross-sectional survey

Background

U.S. physicians lack training in caring for patients with obesity. For family medicine, the newly developed Obesity Medicine Education Collaborative (OMEC) competencies provide an opportunity to compare current training with widely accepted standards. We aimed to evaluate the current state of obesity training in family medicine residency programs.

Methods

We conducted a study consisting of a cross-sectional survey of U.S. family medicine residency program leaders. A total of 735 directors (including associate/assistant directors) from 472 family medicine residency programs identified from the American Academy of Family Physicians public directory were invited via postal mail to complete an online survey in 2018.

Results

Seventy-seven program leaders completed surveys (16% response rate). Sixty-four percent of programs offered training on prevention of obesity and 83% provided training on management of patients with obesity; however, 39% of programs surveyed reported not teaching an approach to obesity management that integrates clinical and community systems as partners, or doing so very little. Topics such as behavioral aspects of obesity (52%), physical activity (44%), and nutritional aspects of obesity (36%) were the most widely covered (to a great extent) by residency programs. In contrast, very few programs extensively covered pharmacological treatment of obesity (10%) and weight stigma and discrimination (14%). Most respondents perceived obesity-related training as very important; 65% of the respondents indicated that expanding obesity education was a high or medium priority for their programs. Lack of room in the curriculum and lack of faculty expertise were reported as the greatest barriers to obesity education during residency. Only 21% of the respondents perceived their residents as very prepared to manage patients with obesity at the end of the residency training.

Conclusion

Family medicine residency programs are currently incorporating recommended teaching to address OMEC competencies to a variable degree, with some topic areas moderately well represented and others poorly represented such as pharmacotherapy and weight stigma. Very few program directors report their family medicine residents are adequately prepared to manage patients with obesity at the completion of their training. The OMEC competencies could serve as a basis for systematic obesity training in family medicine residency programs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-021-01484-y.

The Relationship between Bodyweight Status and Weight Perception Explains Differences in Calories Ordered in a Food Choice Exercise

Understanding food choice is critical to be able to address the rise in obesity rates around the globe. In this paper, we examine the relationship between measured (BMI, using self-reported height and weight) and perceived weight status with the number of calories ordered in a controlled online food choice exercise. A total of 1044 participants completed an online food choice exercise in which they selected ingredients for a sandwich from five categories: meat/protein, cheese, spread/dressing, bread, and vegetables. We examine the number of calories ordered by participants and use linear regression to study the relationship of BMI category relative to self-reported perceived weight status with calories ordered. As a comparison to previous literature, we also examine the relationship between relative weight status and self-reported dieting behavior using logistic regression. We find that participants perceiving themselves to have a higher BMI than their BMI calculated using height and weight ordered significantly fewer calories and were more likely to report dieting than participants who perceived themselves to have a lower BMI than their calculated BMI. The relationship between perceived weight status and measured weight status explains behavior in a food choice task. Understanding how people perceive their weight may help design effective health messages.

Behavioral weight management interventions in metabolic and bariatric surgery: A systematic review and meta-analysis investigating optimal delivery timing

Metabolic and bariatric surgery (MBS) yields unprecedented clinical outcomes, though variability is high in weight change and health benefits. Behavioral weight management (BWM) interventions may optimize MBS outcomes. However, there is a lack of an evidence base to inform their use in practice, particularly regarding optimal delivery timing. This paper evaluated the efficacy of BWM conducted pre- versus post- versus pre- and post-MBS. The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and included pre- and/or post-operative BWM interventions in adults reporting anthropometric and/or body composition data. Thirty-six studies (2,919 participants) were included. Post-operative BWM yielded greater decreases in weight (standardized mean difference [SMD] = -0.41; 95% confidence interval [CI]: -0.766 to -0.049, p < 0.05; I² = 93.5%) and body mass index (SMD = -0.60; 95% CI: -0.913 to -0.289, p < 0.001; I² = 87.8%) relative to comparators. There was no effect of BWM delivered pre- or joint pre- and post-operatively. The risk of selection and performance bias was generally high. Delivering BWM after MBS appears to confer the most benefits on weight, though there was high variability in study characteristics and risk of bias across trials. This provides insight into the type of support that should be considered post-operatively.

Dietary views and habits of students in health professional vs. non-health professional graduate programs in a single university

CONTEXT

Students enrolled in health professional (HP) programs receive varying amounts of credit hours dedicated to nutritional education, and obesity remains an issue in the United States among healthcare providers.

OBJECTIVES

To assess whether HP students differ in nutrition and exercise habits from non-health professional (NHP) students at a single university, and whether any gender-related differences existed in those habits.

METHODS

From September 25, 2018 to October 10, 2019, a 16-question multiple-choice survey was distributed via e-mail or in person to HP and NHP students enrolled at Nova Southeastern University (NSU) in Fort Lauderdale, Florida. Questions targeted participant dietary and exercise habits. Each question had five multiple-choice answer options, each of which was assigned a coded value to compare similarities and differences between the HP and NHP groups.

RESULTS

Of 732 responses (569 HP, 163 NHP), results showed no statistically significant difference between enrollment groups (p>0.05) in any response parameter including consumption of sweets, fast food, red meat, caffeine, water, fruit, and vegetables. Comparisons among sexes demonstrated significant differences. Women consumed less red meat, water, and protein, and women participated in less exercise compared to men. Women also consumed more sweets compared to men.

CONCLUSIONS

Results suggest that NSU students enrolled in HP and NHP programs have similar nutritional concepts and eating habits. This may indicate a need to strengthen nutritional education in dietary health and wellness for HP students.

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.

Physicians certified by the American Board of Obesity Medicine provide evidence-based care

Our objective was to determine the clinical services offered by American Board of Obesity Medicine (ABOM) Diplomates and whether guideline concordant services varied by clinical practice attributes. We conducted a cross-sectional analysis of the 2019 ABOM Diplomate survey (response rate 19.2%). Respondents (n = 494) self-reported services offered: nutrition, exercise, mental health, minimally invasive bariatric procedures, perioperative bariatric surgical care and FDA-approved anti-obesity medications. We graded concordance of services offered with three evidence-based obesity guidelines, and then conducted bivariate analyses comparing concordance by practice attributes. Most responding ABOM Diplomates offered nutrition (90.1%), exercise (67.8%) and mental health (76.7%). Few offered minimally invasive procedures (24.3%), and most provided perioperative surgical care (63.0%). Most (83.4%) prescribed FDA-approved medications-typically both short- and long-term agents (70.9%). Few Diplomates had low concordance with the American Heart Association/American College of Cardiology/The Obesity Society (AHA/ACC/TOS) guidelines (24.7%). Those who managed more obesity-related conditions and endorsed AHA/ACC/TOS guideline use had higher concordance with these recommendations. No differences in guideline concordance existed by population, clinical effort or location. We found similar findings regarding concordance with ) American Association of Clinical Endocrinologists/American College of Endocrinology and Obesity Medicine Association guidelines. In conclusion, most responding ABOM Diplomates offer evidence-based obesity medicine services. Clinicians may therefore have increased confidence in patient receipt of evidence-based care when referring to an ABOM Diplomate.

Analysis of American Medical Students' Knowledge of Physical Activity Recommendations

INTRODUCTION

The benefits of physical activity (PA) are widely recognized; American medical schools have begun to emphasize PA, but the effectiveness of these changes is unclear.

METHODS

We performed a cross-sectional analysis of medical students enrolled in US osteopathic and allopathic medical schools between August 2019 and May 2020. All participants completed an electronic survey about PA instruction across the 4 years of medical school. Objective information including hours and format of PA instruction was collected. Subjectively, participants reported their relative comfort discussing various aspects of PA education with patients.

RESULTS

A total of 480 medical students completed the survey, representing 82 of the 192 US medical schools (69 allopathic, 13 osteopathic). Students are more comfortable discussing overall exercise benefits than exercise testing, exercise prescription, and exercise physiology (P<.0001). They also report more exposure to general PA guidelines related to overall PA duration than strength training (P<.0001). Students at allopathic and osteopathic schools reported similar outcomes regarding PA education, while students with class sizes under 200 reported increased familiarity with National Physical Activity Guidelines regarding PA duration (P<.0001) and strength training (P=.01).

CONCLUSION

Despite recent efforts to improve PA education in medical school, students feel unprepared to apply their knowledge in a clinical setting and remain unaware of national PA guidelines. Future studies should determine how to practically integrate PA education longitudinally into curricula to change PA education from an afterthought to an essential component of medical school education.

Influence of physicians' BMI on counseling practice for obesity in primary health care clinics in Aljouf region, Saudi Arabia. A cross-sectional study

Objectives:

Methods:

Results:

Conclusion:

The "difficult" cadaver: weight bias in the gross anatomy lab

Background: The prevalence of overweight and obesity continues to rise and is associated with increased morbidity and mortality. Weight bias is common among physicians and medical students and limits the therapeutic alliance between providers and patients with overweight and obesity.Objective: The authors sought to explore the relationship between the gross anatomy course and medical student attitudes towards weight and obesity.Design: The authors employed a mixed-methods approach consisting of semi-structured interviews and anonymous web-based surveys of first-year medical students taking gross anatomy at one USA medical school. They analyzed transcripts of interviews and free-text survey responses using a grounded theory approach and performed tests of association to investigate the relationship between demographic information, responses to multiple-choice survey questions and weight bias.Results: A total of 319 (52%) first-year medical students (2015-2018) completed the survey and 33 participated in interviews. Of survey respondents, 71 (22%) responded that the course had changed how they felt about people with overweight/obesity. These respondents were also more likely to affirm that the course had affected their views toward their own bodies (p < 0.001). Qualitative data analysis identified three overarching themes within students' descriptions of the effects of the gross anatomy lab on attitudes toward bodies perceived to have excess weight: these bodies were described as 1) difficult, 2) unhealthy, and 3) evoking disgust. Students extrapolated from their experiences with cadavers to imagined interactions with future patients, relying heavily on the narrative of the difficult patient.Conclusions: At one USA medical school, students perceived their experiences in gross anatomy as shaping their attitudes toward individuals with overweight or obesity. Efforts to reduce medical student weight bias ought to target this previously unexplored potential site of weight bias.

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.

Nurse practitioner students' observations of preceptor engagement in obesity management and weight bias: A mixed-methods approach

BACKGROUND

Obesity is considered a growing epidemic in the United States. Nurse practitioners (NPs) have the opportunity to serve as leaders in addressing concerns related to disease management, particularly obesity. Currently, we lack an awareness of how NP students are learning obesity management from their preceptors.

PURPOSE

Thus, the current study sought to explore how NP students perceive preceptors' behaviors when managing patients with obesity.

METHODOLOGICAL ORIENTATION

This study used a mixed-methods design. Participants were asked to report how often they observed their preceptors engage in different strategies when interacting with patients with obesity (e.g., calculate body mass index, identify goals). Students were then asked to respond to the statement: "share observations you made of how patients with obesity were treated in this environment." Students completed 2 clinical rotations during this period and, thus, were asked to answer the questions twice to capture experiences at both clinical sites.

SAMPLE

Researchers surveyed 225 NP students completing clinical rotations in 3 settings (Family Practice, Pediatrics, and Obstetrics/Gynecology).

CONCLUSIONS

Quantitative results revealed significant differences in the frequency of observed obesity management behaviors by all preceptors. Qualitative results revealed that NP students most often observed preceptors displaying interpersonal warmth without weight bias when working with patients with obesity. Contrary to current literature, this sample of NP students observed their preceptors engaging in positive interactions with individuals with obesity.

IMPLICATIONS FOR PRACTICE

Educators must continue to teach students to engage in unbiased behavior toward patients. It is critical to continue to improve obesity management content offered in NP programs.

Identifying Opportunities for Advancing Weight Management in Primary Care

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Medicine Residents are Unprepared to Effectively Treat Patients with Obesity: Results from a U.S. Internal Medicine Residency Survey

BACKGROUND

In an obesity epidemic, physicians are unprepared to treat patients with obesity. The objective of this study was to understand how obesity is currently addressed in United States (U.S.) Internal Medicine (IM) residency programs and benchmark the degree to which curricula incorporate topics pertaining to the recently developed Obesity Medicine Education Collaborative (OMEC) competencies.

METHODS

Invitations to complete an online survey were sent via postal mail to U.S IM residency programs in 2018. Descriptive analyzes were performed.

RESULTS

Directors/associate directors from 81 IM residencies completed the online survey out of 501 programs (16.2%). Although obesity was an intentional educational objective for most programs (66.7%), only 2.5% of respondents believed their residents are "very prepared" to manage obesity. Formal rotation opportunities in obesity are limited, and at best, only one-third (34.6%) of programs reported any one of the core obesity competencies are covered to "a great extent." Many programs reported psychosocial components of obesity (40.7%), weight stigma (44.4%), etiological aspects of obesity (64.2%) and pharmacological treatment of obesity (43.2%) were covered to "very little extent" or "not at all." Lack of room in the curriculum and lack of faculty expertise are the greatest barriers to integrating obesity education; only 39.5% of residency programs have discussed incorporating or expanding formal obesity education.

CONCLUSIONS

Our study found the current obesity curricula within U.S. IM residency programs do not adequately cover important aspects that address the growing obesity epidemic, suggesting that obesity education is not enough of a priority for IM residency programs to formalize and implement within their curricula.

Geographic Availability of Physicians Certified by the American Board of Obesity Medicine Relative to Obesity Prevalence

OBJECTIVE

The objective of this study is to determine the distribution of adult and pediatric American Board of Obesity Medicine (ABOM) diplomates relative to the prevalence of obesity by US state.

METHODS

Data from the ABOM physician directory were used to determine original specialty and US state. Physicians were labeled as "adult medicine" physicians (i.e., internal medicine, family medicine, or internal medicine and pediatrics), "pediatric medicine" physicians (i.e., pediatrics, family medicine, or internal medicine and pediatrics), and "other physicians" (i.e., surgical specialty, other specialty, or unknown). Prevalence of obesity by state, according to the Centers for Disease Control and Prevention, was used for adults and adolescents in 2017 and for children in 2014. Counts of ABOM-certified adult medicine physicians and pediatric medicine physicians were conducted relative to obesity prevalence by state.

RESULTS

A total of 2,577 US-based ABOM-certified physicians were included (79% from adult medicine, 38% from pediatric medicine, and 15% from other fields). All US states had more than one ABOM-certified adult medicine physician, although geographic disparities existed in physician availability relative to obesity prevalence. Fewer pediatric medicine ABOM diplomates were available in all states.

CONCLUSIONS

Promotion of ABOM training and certification in certain geographic locations and among pediatric physicians may help address disparities in ABOM diplomate availability relative to obesity burden.

Influence of weight etiology information and trainee characteristics on Physician-trainees' clinical and interpersonal communication

OBJECTIVE

This analysis explores the effects of relaying information about the genetic and behavioral causes of obesity (vs. control) on physician trainees' verbal communication behavior with a virtual patient with obesity. Moderation by physician trainees' gender and BMI was also assessed.

METHODS

119 physician trainees' verbal responses were recorded and coded using a close-ended content analytic approach.

RESULTS

Physician trainees in the behavioral and genetic information conditions were more likely to discuss weight (behavioral: AOR = 5.40; genetic: AOR = 6.58,) and provide lifestyle counseling (behavioral: AOR = 10.92; genetic: AOR = 3.50). Those in the behavioral condition were more likely to make assumptions about the patient's lifestyle behavior (AOR = 5.53) and use stigmatizing language (AOR = 4.69). Heavier physician trainees in the genetic condition had shorter interactions (β = -0.53, p <  0.01).

CONCLUSION

Emphasizing the genetic causes of overweight offers a potential avenue for encouraging clinical communication with patients with obesity, without also increasing prejudice and bias. Additional efforts may be needed to reap the benefits of genetic information for providers with higher weight.

PRACTICE IMPLICATIONS

For providers, considering genetic factors underlying patient body weight and obesity risk may serve to reduce stigmatizing communication with patients.

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

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

Patient perceptions of primary care providers' knowledge of bariatric surgery

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

Perception and Management of Obesity Among Pakistani Doctors

Background The incidence of obesity has been on the rise worldwide. In Pakistan alone, one in four adults is overweight/obese and thus at risk of developing a number of comorbidities such as cardiovascular disease and diabetes. This research aimed to examine how doctors perceived and managed their obese patients. Methods A standardized questionnaire was filled by 100 doctors working in Pakistan, either by hand or online. The study was conducted from November 2017 to January 2018. Results It was found that only 8% of doctors had completed a training course on obesity. Doctors discussed the links between obesity and diabetes (88%) most often whilst neglecting cancer (30%) and dementia (17%). Only 60% of doctors calculated body mass index (BMI) for adult obese patients, with general practitioners (GPs) being the most confident in discussing their weight issues (p=0.001). In terms of childhood obesity, 54% of doctors were confident in putting in place a weight management program. Doctors who checked their weight more than four times a year were found to calculate the BMI of children and adult patients more often (p=0.000 and p=0.044). Comparably, doctors of normal weight were more confident in managing the complications of adult obesity (p=0.015). Conclusion Training courses regarding obesity should be provided to doctors not only to increase their knowledge but also to increase their confidence levels in managing such patients. Further research needs to be carried out in order to understand the patients' perception of obesity management.

Associations between medical students' beliefs about obesity and clinical counseling proficiency

Background

Despite evidence that biological and genetic factors contribute strongly to obesity, many healthcare providers still attribute obesity more to controllable behavioral issues rather than factors outside a person’s control. We evaluated whether medical school students’ beliefs about obesity correlate with ability to effectively counsel patients with obesity.

Methods

Clerkship-year medical students at NYU School of Medicine completed an Objective Structured Clinical Experience (OSCE) that tests ability to effectively counsel standardized actor-patients with obesity. We surveyed these students to evaluate their beliefs about the causes of obesity and their attitudes towards people with obesity. We analyzed correlations between student beliefs, negative obesity attitudes, and OSCE performance.

Results

The response rate was 60.7% (n = 71). When asked to rate the importance of individual factors, students rated controllable factors such as unhealthy diet, physical inactivity, and overeating as more important than genetics or biological factors (p < 0.01). Believing obesity is caused by uncontrollable factors was negatively correlated with obesity bias (r = − 0.447; p < 0.0001). Believing that obesity is caused by factors within a person’s control was negatively correlated with counseling skills (r = − 0.235; p < 0.05).

Conclusions

Attribution of obesity to external factors correlated with greater ability to counsel patients with obesity, suggesting that educating providers on the biological causes of obesity could help reduce bias and improve provider care.

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

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

Exploring obstetricians', midwives' and general practitioners' approach to weight management in pregnant women with a BMI ≥25 kg/m2: a qualitative study

OBJECTIVE

The aim of this study was to explore healthcare professionals' (HCPs) beliefs and attitudes towards weight management for pregnant women with a body mass index (BMI) ≥25 kg/m².

DESIGN

Qualitative study.

SETTING

A public antenatal clinic in a large academic maternity hospital in Cork, Ireland, and general practice clinics in the same region.

PARTICIPANTS

HCPs such as hospital-based midwives and consultant obstetricians and general practitioners (GPs).

METHOD

Semistructured interviews were conducted with a purposive sample of hospital-based HCPs and a sample of GPs working in the same region. Interviews were recorded, transcribed and thematically analysed using NVivo software.

RESULTS

Seventeen HCPs were interviewed (hospital based=10; GPs=7). Four themes identified the complexity of weight management in pregnancy and the challenges HCPs faced when trying to balance the medical and psychosocial needs of the women. HCPs acknowledged weight as a sensitive conversation topic, leading to a 'softly-softly approach' to weight management. HCPs tried to strike a balance between being woman centred and empathetic and medicalising the conversation. HCPs described 'doing what you can with what you have' and shifting the focus to managing obstetric complications. Furthermore, there were unclear roles and responsibilities in terms of weight management.

CONCLUSION

HCPs need to have standardised approaches and evidence-based guidelines that support the consistent monitoring and management of weight during pregnancy.

Lifestyle intervention for obesity: a call to transform the clinical care delivery system in Mexico

Obesity and its comorbidities have become the most important public health problems for Latin America. In Mexico obesity has increased dramatically to the point where the government has declared it an epidemiological emergency. The most recent national data showed overweight and obesity affects 72.5% of adults, or around 56 million Mexicans. Most Mexican adults with obesity are undiagnosed. According to data derived from a national representative survey, only 20% of adults with BMI >30 kg/m² were diagnosed with obesity by a health provider. Likewise, only 8% of individuals with obesity had received treatment for obesity. Interventions offered in the Mexican health care delivery system generally consist of traditional consultations with recommendations on diet and exercise, visits are monthly to quarterly, and validated behavior change protocols are not used. Evidence from clinical trials has shown that weight loss with this type of treatment is generally less than 1 kg per year. In contrast, intensive lifestyle interventions - protocols focusing on achieving changes in diet, physical activity, and moderate weight loss using behavioral strategies with weekly or bi-weekly sessions for the first 3 to 6 months, and a maintenance phase with trained interventionists - as implemented in the Diabetes Prevention Program and the Look AHEAD studies achieved weight loss of 7-9% at one year. Additionally, translation studies of these interventions to the community and to real-world clinical practice have achieved weight loss of around 4%. Adaptations of intensive lifestyle interventions have been implemented in the United States, both in clinical practice and in the community, and this type of intervention represents a potential model to combat obesity in Mexico and other Latin American countries. It is essential that primary care providers in Mexico implement clinical practice guidelines based on the best evidence available as discussed here to effectively treat obesity. The authors make recommendations to improve the treatment of obesity in the clinical care delivery system in Mexico using intensive lifestyle interventions.

Students' Report of Preceptor Weight Management Counseling at Eight U.S. Medical Schools

INTRODUCTION

Primary care providers, using brief counseling, can help patients increase motivation to initiate or maintain weight loss, improve diet, and increase physical activity. However, no prior studies have examined the degree to which primary care preceptors, who are responsible for mentoring medical students during their core clerkships, provide clinical teaching regarding weight management counseling.

METHODS

Medical students enrolled in eight U.S. medical schools who had finished their preclinical coursework completed surveys in the spring of 2016 to assess preceptor communication, modeling, feedback, and instruction in weight management counseling, as well as educational cues for patients and chart reminders for physicians. Analysis was completed in 2017 and 2018.

RESULTS

Of 738 students completing the survey, the most recent completed clerkships were obstetrics and gynecology (38.1%), family medicine (32.1%), and internal medicine (29.8%). Students in family medicine clerkships reported higher levels of weight management counseling clinical teaching than students completing an internal medicine or obstetrics and gynecology clerkship. Among the main variables of interest across all three clerkships, only 13%-24% of students agreed that preceptors provided clear objectives for learning weight management counseling, and 13%-25% of students agreed that preceptors provided feedback.

CONCLUSIONS

Even with a U.S. Preventive Services Task Force recommendation for primary care physicians to provide weight management counseling and endorsement from the major academic primary care societies, students in primary care clerkships report receiving little weight management counseling clinical teaching from their preceptors. The results reinforce the need for medical educators to teach and model weight management counseling for physicians-in-training if they are to achieve Task Force goals. Further research is required to better corroborate self-reported indicators of preceptor to student communication that are described herein.

Underdocumentation of Obesity by Medical Residents Highlights Challenges to Effective Obesity Care

OBJECTIVE

The goal of this study was to determine attitudes and practices of physicians in training with respect to the evaluation and treatment of obesity.

METHODS

Resident-generated admission and discharge notes of all 1,765 general medicine hospital admissions during 4 nonconsecutive months were analyzed, and any references to weight, obesity, BMI, adiposity, and body fat were identified. The full general resident cohort was then surveyed for perceptions and behaviors related to obesity.

RESULTS

Obesity was considered a highly important medical issue by 98.5% of residents; 90% correctly identified a class II obesity Stunkard phenotype, and 80% accurately calculated a BMI given height and weight in metric units. Residents overestimated inpatient obesity prevalence (estimate = 75%; actual = 35%) and the rate of obesity recording in the hospital admission note (estimate = 94%; actual = 49.5%). A BMI or current weight in the admission note or discharge summary was reported in none of the 1,765 patient records, and only 6% of the patients with obesity had obesity noted in either the inpatient admission or discharge assessment or plan.

CONCLUSIONS

Though residents recognize obesity and its clinical implications, it is underreported in the assessment of inpatients. This low level of documenting obesity and its impact on clinical care planning underscores a missed opportunity to establish appropriate referrals and initiate treatment at a clinically opportune time.

Obesity Prevention and Management Strategies in Canada: Shifting Paradigms and Putting People First

PURPOSE OF REVIEW

The purpose of this study was to review public and private sector obesity policies in Canada and to make recommendations for future evidence-based obesity prevention and management strategies.

RECENT FINDINGS

Synthesis of obesity prevention and management policies and research studies are presented in three primary themes: (1) Increased awareness about the impact of weight bias and obesity stigma in Canada; (2) Inadequate government obesity prevention and management policies and strategies; and (3) Lack of comprehensive private sector obesity prevention and management policies. Findings suggest that in Canada, obesity continues to be treated as a self-inflicted risk factor, which affects the type of interventions and approaches that are implemented by governments or covered by private health plans. The lack of recognition of obesity as a chronic disease by Canadian public and private payers, health systems, employers, and the public, has a trickle-down effect on access to evidence-based prevention and treatment. Although there is increasing recognition and awareness about the impact of weight bias and obesity stigma on the health and social well-being of Canadians, interventions are urgently needed in education, healthcare, and public policy sectors. We conclude by making recommendations for the advancement of evidence-based obesity prevention and management policies that can improve the lives of Canadians affected by obesity.

A Narrative Review of Physician Perspectives Regarding the Social and Environmental Determinants of Obesity

PURPOSE OF REVIEW

Diet-related chronic diseases result from individual and non-individual (social, environmental, and macro-level) factors. Recent health policy trends, such as population health management, encourage assessment of the individual and non-individual factors that cause these diseases. In this review, we evaluate the physician's perspective on the individual and non-individual causes and management of obesity.

RECENT FINDINGS

Physicians generally rated individual-level causes (i.e., biology, psychology, and behavior) as more important than social or environmental factors in the development of obesity, and utilized individual-level strategies over social or environmental strategies to manage obesity. This review suggests that clinicians perceive individual characteristics to be more important in the development and management of obesity than social or environmental factors. Additional research is needed to understand why.

Assessing and counseling the obese patient: Improving resident obesity counseling competence

OBJECTIVE

To evaluate obesity counseling competence among residents in a primary care training program METHODS: We delivered a 3h obesity curriculum to 28 Primary Care residents and administered a pre-curriculum and post curriculum survey looking specifically at self-assessed obesity counseling competence.

RESULTS

Nineteen residents completed both the pre curriculum survey and the post curriculum survey. The curriculum had a positive impact on residents' ability to ascertain patient's stage of change, use different methods to obtain diet history (including 24h recall, food record or food frequency questionnaire), respond to patient's questions regarding treatment options, assist patients in setting realistic goals for weight loss based on making permanent lifestyle changes, and use of motivational interviewing to change behavior. When looking at the 5As domains, there was a significant improvement in the domains of Assess, Advise, and Assist. The proportion of residents with a lower level of self-assessed obesity counseling competence reduced from 75% before the curriculum to 37.5% (p=0.04) after the curriculum.

CONCLUSION

Our curriculum addressing weight loss counseling using the 5As model increased obesity counseling competence among residents in a primary care internal medicine residency program.

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.

Conduction, Evaluation, and Future Considerations for an Obesity Educator Training Program in Korea

To reduce the prevalence of obesity and provide information on evidence-based obesity treatments, the Education Committee of the Korean Society for the Study of Obesity (KSSO) has developed and launched the first Obesity Educator Training Program (OETP). After the course, we analyzed the results of a survey from 110 participants, comprising medical doctors (n=58), nutrition specialists (n=19), exercise specialists (n=14), and students (n=6). Approximately half of the participants were recruited through the Internet (48%), followed by academic leaflets, such as conference posters (21%); the reasons for participation were to learn about evidence-based treatments for obesity (47%), to receive up-to-date knowledge on obesity treatments (39%), to obtain basic information on obesity (10%), and others (4%). More than half of the participants found the date, lecture time, process, and theme of the OETP favorable. The participants indicated that there should be an in-depth course, sharing of the presented files with attendees, a longer lecture time, and a broader OETP that includes other specialties such as nursing. To improve the OETP, the educational committee of the KSSO must develop an in-depth OETP that will reflect these participant's feedback.

Primary Care Resident Training for Obesity, Nutrition, and Physical Activity Counseling: A Mixed-Methods Study

National guidelines have been established to support the role of primary care physicians in addressing obesity. Preparing primary care residents to recognize and treat overweight/obesity has been identified as an essential component of postgraduate medical training that is currently lacking. This study aims to identify how primary care residency programs are preparing physicians to counsel about obesity, nutrition, and physical activity (ONPA) and to examine program members' perspectives regarding the place of ONPA counseling in the curriculum, and its relevance in primary care training. Using mixed methods, we collected and analyzed data on 25 family medicine, internal medicine, and obstetrics/gynecology residency programs across Ohio. Programs averaged 2.8 hours of ONPA-related didactics per year. Ten programs (42%) taught techniques for health behavior counseling. Having any ONPA-related didactics was associated with greater counseling knowledge (p = .01) among residents but poorer attitudes (p < .001) and poorer perceived professional norms (p = .004) toward ONPA counseling. Findings from interview data highlighted similar perceived barriers to ONPA counseling across all three specialties but variation in perception of responsibility to provide ONPA counseling. While widespread expectations that primary care physicians counsel their overweight and obese patients prevail, few residency programs provide training to support such counseling.

Treatment of Obesity Among Youth With Intellectual and Developmental Disabilities: An Emerging Role for Telenursing

Childhood obesity is a serious health issue, associated with medical comorbidity and psychosocial impairment that can persist into adulthood. In the United States, youth with intellectual and developmental disabilities are more likely to be obese than youth without disabilities. A large body of evidence supports the efficacy of family-based treatment of childhood obesity, including diet, physical activity, and behavior modification, but few interventions have been developed and evaluated specifically for this population. We highlight studies on treatment of obesity among youth with intellectual and developmental disabilities, including both residential/educational settings as well as outpatient/hospital settings. All interventions were delivered in-person, and further development of promising approaches and delivery via telenursing may increase access by youth and families. Nursing scientists can assume an important role in overcoming barriers to care for this vulnerable and underserved population.

Increasing general practitioners' confidence and self-efficacy in managing obesity: a mixed methods study

OBJECTIVES

Internationally, general practitioners (GPs) are being encouraged to take an active role in the care of their patients with obesity, but as yet there are few tools for them to implement within their clinics. This study assessed the self-efficacy and confidence of GPs before and after implementing a weight management programme in their practice.

DESIGN

Nested mixed methods study within a 6-month feasibility trial.

SETTING

4 urban general practices and 1 rural general practice in Australia.

PARTICIPANTS

All vocationally registered GPs in the local region were eligible and invited to participate; 12 GPs were recruited and 11 completed the study.

INTERVENTIONS

The Change Programme is a structured GP-delivered weight management programme that uses the therapeutic relationship between the patient and their GP to provide holistic and person-centred care. It is an evidence-based programme founded on Australian guidelines for the management of obesity in primary care.

PRIMARY OUTCOME MEASURES

Self-efficacy and confidence of the GPs when managing obesity was measured using a quantitative survey consisting of Likert scales in conjunction with pro forma interviews.

RESULTS

In line with social cognitive theory, GPs who experienced performance mastery during the pilot intervention had an increase in their confidence and self-efficacy. In particular, confidence in assisting and arranging care for patients was improved as demonstrated in the survey and supported by the qualitative data. Most importantly from the qualitative data, GPs described changing their usual practice and felt more confident to discuss obesity with all of their patients.

CONCLUSIONS

A structured management tool for obesity care in general practice can improve GP confidence and self-efficacy in managing obesity. Enhancing GP 'professional self-efficacy' is the first step to improving obesity management within general practice.

TRIAL REGISTRATION NUMBER

ACTRN12614001192673; Results.

Obesity Knowledge among Final-Year Medical Students in Norway

OBJECTIVES

To assess the level of obesity knowledge in final-year medical students in Norway and to compare it to an expert group and first-year medical students.

METHODS

A 20-item questionnaire was specifically designed for this purpose (18 knowledge-based questions and 2 subjective questions looking at attitudes and self-perceived proficiency). All medical schools in Norway were included (n = 226). For comparison purposes, an expert group (n = 13) and first-year medical students (n = 96) were included.

RESULTS

Experts (81%; 15 out of 18 (13.5-16.0)) scored significantly higher than both final-year (60%; 11 out of 18 (9.0-12.0)) and first-year (48%; 9 out of 18 (7.0-10.0)) students. Final-year students scored significantly higher than first-year students, but showed inadequate obesity knowledge, especially with regard to etiology, diagnosis, and treatment aspects. Subjective questions revealed that medical students trust their acquired knowledge, but feel pressured by time constraints and the complexity of lifestyle issues and experience barriers to long-term follow-up.

CONCLUSION

Final-year medical students in Norway show an inadequate knowledge level within the obesity field, although a significant improvement is seen during the course of medical education. They also show a high self-perceived proficiency in dealing with obesity, despite several constraints/barriers.