Weight management practices among primary care providers

Discussing lifestyle behaviors: perspectives and experiences of general practitioners

Background: Initiatives aimed at increasing participation in preventive health behaviors has been identified as a priority for addressing the increasing incidence of non-communicable chronic disease. General practice is an existing network that can be leveraged to intervene and promote messages for health behavior change. We aimed to explore the extent to which ‘lifestyle’ behaviors are discussed by general practitioners (GPs) with their patients in their practices, and the context and content of these discussions.

Methods: GPs (N = 26) practising in Australian clinics participated in semi-structured interviews. Data were analyzed using an inductive thematic analysis.

Results: Results showed discussions of lifestyle behaviors were brief, but relatively frequent and often initiated by the GP. GPs generally provided basic advice and education that was often ad-hoc and in reaction to prompts from the patient. GPs recognized the importance of addressing lifestyle behaviors in practice, but also highlighted substantive barriers that limit the initiation of these discussions. These included patient readiness for change, patient acceptance and openness, patient accountability and responsibility, patient background factors, GPs’ role and knowledge, GP financial implications, GP-patient relationship, and lack of time.

Conclusions: Current findings provide important preliminary knowledge on the extent to which Australian GPs discuss lifestyle behavior change with patients during routine consultations, the context and content of these discussions, and barriers to initiating these discussions. Further research should seek to gain a better understanding of barriers and identify strategies to mitigate their impact. This might maximize the potential for GPs to promote adaptive lifestyle behavior change for improving patient health.

The Incomplete Medicalization of Obesity: Physician Office Visits, Diagnoses, and Treatments, 1996-2014

OBJECTIVES

Despite increased awareness of obesity-related health risks and myriad treatment options, obesity still affects more than one-third of persons in the United States and is a substantial public health problem. Studies show that physicians play a key role in obesity prevention and treatment. The objective of this study was to examine the extent to which obesity is diagnosed and treated at the level of patient-physician interaction.

METHODS

We used data from the National Ambulatory Medical Care Survey (NAMCS), a nationally representative data set of US physician office visits. We estimated the number of obesity diagnoses and prescriptions of weight-loss management solutions (exercise counseling, diet counseling, or weight-loss drugs) in clinical practice from 1996 through 2014. We also calculated rates of obesity diagnosis and compared these rates with national rates of obesity based on body mass index data from the Behavioral Risk Factor Surveillance System (BRFSS) for the same period.

RESULTS

The estimated number of weight gain-related physician office visits increased from 2.3 million in 1996 to a peak of 7.6 million in 2012, and then fell to 4.5 million in 2014. National estimates of obesity diagnoses resulting from physician office visits ranged from 7.1 million in 1996 to 12.7 million in 2014 and substantially outnumbered the estimates for weight gain-related physician office visits throughout the study period. Estimates of exercise counseling and diet counseling and weight-loss medication prescriptions resulting from physician office visits fluctuated over time but never exceeded obesity diagnoses. When compared with national rates of obesity from the BRFSS, rates of obesity diagnoses resulting from physician office visits were substantially lower in the NAMCS (17%-30% vs 1%). National trends for weight-loss medication prescriptions closely mirrored those of weight gain-related physician office visits, even though fluctuations were substantial.

CONCLUSIONS

Our results suggest that obesity is largely underdiagnosed and undertreated in clinical encounters. Future studies should investigate the structural changes needed to better engage physicians in obesity prevention and care. Practitioners should also reflect on their biases in treating obesity as a chronic disease.

Practice patterns of nurse practitioners related to weight management in primary care

BACKGROUND AND OBJECTIVES

Obesity prevalence rates for adults are at an all-time high. This systematic review of the literature aimed to examine the practice patterns of nurse practitioners (NPs) related to weight management in primary care and recommend future areas of research as it relates to the diagnosis and management of patients with obesity by NPs.

DATA SOURCES

The databases CINAHL PLUS with Full Text, Cochrane Central Register of Controlled Trials, ERIC, MEDLINE, PsycINFO, and SPORTDiscuss were searched.

CONCLUSIONS

The initial search resulted in 169 articles. Fifteen peer-reviewed articles from 13 studies were included in the analysis. Four themes emerged from the analysis: approach to practice; the practitioner's role within the interdisciplinary team; communication; and resources and tools.

IMPLICATIONS FOR PRACTICE

This review was conducted to better understand the challenges and facilitators to the management of patients with obesity in primary care. Future research between NPs and variables related to obesity are necessary to further identify areas for education, training, and policy development.

Role of the family doctor in the management of adults with obesity: a scoping review

OBJECTIVES

Obesity management is an important issue for the international primary care community. This scoping review examines the literature describing the role of the family doctor in managing adults with obesity. The methods were prospectively published and followed Joanna Briggs Institute methodology.

SETTING

Primary care. Adult patients.

INCLUDED PAPERS

Peer-reviewed and grey literature with the keywords obesity, primary care and family doctors. All literature published up to September 2015. 3294 non-duplicate papers were identified and 225 articles included after full-text review.

PRIMARY AND SECONDARY OUTCOME MEASURES

Data were extracted on the family doctors' involvement in different aspects of management, and whether whole person and person-centred care were explicitly mentioned.

RESULTS

110 papers described interventions in primary care and family doctors were always involved in diagnosing obesity and often in recruitment of participants. A clear description of the provider involved in an intervention was often lacking. It was difficult to determine if interventions took account of whole person and person-centredness. Most opinion papers and clinical overviews described an extensive role for the family doctor in management; in contrast, research on current practices depicted obesity as undermanaged by family doctors. International guidelines varied in their description of the role of the family doctor with a more extensive role suggested by guidelines from family medicine organisations.

CONCLUSIONS

There is a disconnect between how family doctors are involved in primary care interventions, the message in clinical overviews and opinion papers, and observed current practice of family doctors. The role of family doctors in international guidelines for obesity may reflect the strength of primary care in the originating health system. Reporting of primary care interventions could be improved by enhanced descriptions of the providers involved and explanation of how the pillars of primary care are used in intervention development.

Physicians' views and experiences of discussing weight management within routine clinical consultations: A thematic synthesis

OBJECTIVE

To systematically search and synthesise qualitative studies of physicians' views and experiences of discussing weight management within a routine consultation.

METHODS

A systematic search of four electronic databases identified 11,169 articles of which 16 studies met inclusion criteria. Quality was appraised using the Critical Appraisal Skills Programme tool and a thematic synthesis conducted of extracted data.

RESULTS

Four analytical themes were found: (1) physicians' pessimism about patients' weight loss success (2) physicians' feel hopeless and frustrated (3) the dual nature of the physician-patient relationship (4) who should take responsibility for weight management.

CONCLUSION

Despite clinical recommendations barriers remain during consultations between physicians and patients about weight management. Many of these barriers are potentially modifiable.

PRACTICE IMPLICATIONS

Improving training, providing clearer guidelines and placing a greater emphasis on collaboration within and between clinicians will help reduce barriers for both physicians and patients. In particular, there is an urgent need for more specialised training for physicians about weight management to promote knowledge and skills in behaviour change techniques and ways to broach sensitive topics without damaging patient relationships.

Managing Gestational Weight Gain: Obstetricians' Perceived Barriers and Interventions

To support optimal health outcomes during pregnancy, understanding obstetricians' (OBs) recommendations for and barriers to managing gestational weight gain (GWG) can benefit childbirth educators. This mailed survey examined OBs' practices (n = 63) for managing GWG along with perceived barriers. The most frequent recommendations were (a) increase activity (76.2%), (b) aerobic activity (63.5%), (c) patient education about weight management (61.9%), (d) increase fiber intake (61.3%), and (e) use of guidelines for weight gain (58.7%). Self-tracking weight gain charts were the least used. Greatest barriers to GWG management were (a) patients not interested in changing behavior (77.8%), (b) high relapse rates (66.7%), (c) lack of community resources (60.3%), (d) patients cannot afford referrals (58.7%), and (e) lack of time (53.9%).

State of the Art Reviews: Relationship Between Diet/ Physical Activity and Health

Obesity and 4 of the leading causes of death—heart disease, cancer, stroke, and type 2 diabetes mellitus—are related to lifestyle. The combination of a healthy weight, prudent diet, and daily physical activity clearly plays a role in primary, secondary, and tertiary prevention of these and other chronic diseases. Because nearly 65% of the adult population is overweight or obese, weight loss and maintenance are central to this review article. Improved lipid profiles, blood pressure, insulin sensitivity, and euglycemia are associated with weight loss or a normal body weight; thus, maintaining a healthy weight is a universal recommendation for health. The methods for improving lifestyle described in the section on obesity include assessing nutritional status and stages of change of the client, setting realistic goals, eating a diet high in fruits and vegetables with low-fat sources of dairy and protein, and achieving appropriate physical activity levels. The importance of physicians discussing weight with clients and vice versa is stressed. The common features of lifestyle-related diseases make them amenable to similar lifestyle interventions.

Starting the conversation: Patient initiation of weight-related behavioral counseling during pregnancy

OBJECTIVE

To examine the relationship between patient initiation and weight-related behavioral counseling during pregnancy.

METHODS

We examined audio recordings of prenatal visits between 22 obstetricians and 120 patients for behavioral counseling using the Roter Interaction Analysis System and the 5A's behavioral counseling framework. We used multivariate regression models to examine the relationship between patient initiation and communication outcomes.

RESULTS

Overall, 55% of prenatal visits included any behavioral counseling. Patients initiated counseling episodes 45.5% of these visits. Patients were less verbally dominated by their clinicians in prenatal visits with patient-initiated behavioral counseling episodes (difference in clinician verbal dominance ratio=0.73, 95% CI=0.16-1.30). Patient-initiated counseling episodes included more socioemotional communication relative to those initiated by clinicians (p=0.02). The total duration of counseling was 28s longer (95% CI 0.27-56.0s) and clinicians were more likely to use two or more 5A's strategies (OR=3.61, 95% CI=1.01-12.88) when patients initiated discussions.

CONCLUSIONS

Patient initiation may lead to behavioral counseling that is longer in duration and includes more 5A's strategies, possibly mediated by socioemotional communication.

PRACTICE IMPLICATIONS

Participatory prenatal care communication may lead to more effective counseling that is responsive to women's concerns.

Guiding patients to safe weight loss

Many patients have questions about diets, and those adhering to specific diets need patient-tailored monitoring. Nurse practitioners are often called upon to advise, prescribe, and monitor specific weight-reduction and weight-control diets. This article provides guidelines for safe weight reduction and a review of some popular diets.

Nursing students' perceptions of obesity and behaviour change: implications for undergraduate nurse education

BACKGROUND

Rates of obesity are rising and previous research suggests this is not effectively dealt with in healthcare settings. Nurses are increasingly involved in lifestyle management of patients, and understanding the barriers to discussing weight with patients is likely to increase successful weight management. Obesity management is a role that nursing students will need to be equipped with and more likely to be targeted for future training developments in tackling the increasing rates of obesity.

OBJECTIVES

To explore the perceptions of obesity, potential barriers to successful patient weight management and training needs of nursing students.

METHODS

Qualitative, semi-structured interviews were conducted with 20 nursing students. Audiotaped interviews were transcribed verbatim and analysed using an inductive thematic approach informed by principles of grounded theory.

RESULTS

Participants reported the challenge of managing obesity in healthcare practice, such as the impact of negative attitudes in healthcare practice on patient care. Although perceived as core to their training, nursing students lacked the confidence and techniques to discuss weight management with patients. Participants also perceived the nursing curriculum as lacking a focus on obesity, and reported a need for advanced communication skills training.

CONCLUSION

Although seen as important, nurses lack the skills to facilitate weight management, leading to nurses failing to broach the issue.

PRACTICE IMPLICATIONS

Nurse educators should consider the perceptions of current students when making curriculum developments in this area.

Overweight and Obesity: Knowledge, Attitudes, and Practices of General Practitioners in France

OBJECTIVE

To describe the current knowledge, attitudes, and practices of French general practitioners (GPs) in the field of adult overweight and obesity management.

RESEARCH METHODS AND PROCEDURES

A cross-sectional telephone survey interviewed a sample of 600 GPs, representative of the private GPs in southeastern France. A four-part questionnaire assessed personal and professional characteristics, attitudes and opinions about overweight and obesity, relevant knowledge and training, and practices (diagnostic methods, clinical assessments, weight loss objectives, types of counseling).

RESULTS

Most GPs knew that weight problems are health-threatening, and 79% agreed that managing these problems is part of their role. Nevertheless, 58% did not feel they perform this role effectively, and one-third did not find it professionally gratifying. Approximately 30% had negative attitudes toward overweight and obese patients; 57% were pessimistic about patients' ability to lose weight; 64% often set weight loss objectives more demanding than guidelines call for; and neither food diaries nor nutritional education were used systematically. GPs' feelings of effectiveness and attitudes toward obese patients were associated with some professional (training) and personal (BMI, personal diet experience) characteristics.

DISCUSSION

GPs' feelings of ineffectiveness may stem from an underlying conflict between practitioners' and patients' representations of weight problems and the relationship problems this causes. Inadequate practices and health care system organization may also play a role.

Impact of patient-doctor race concordance on rates of weight-related counseling in visits by black and white obese individuals

The objective of this study was to assess the impact of patient-provider race concordance on weight-related counseling among visits by obese patients. We hypothesized that race concordance would be positively associated with weight-related counseling. We used clinical encounter data obtained from the 2005-2007 National Ambulatory Medical Care Surveys (NAMCS). The sample size included 2,231 visits of black and white obese individuals (ages 20 and older) to their black and white physicians from the specialties of general/family practice and general internal medicine. Three outcome measures of weight-related counseling were explored: weight reduction, diet/nutrition, and exercise. Logistic regression was used to model the outcome variables of interest. Wald tests were used to statistically compare whether physicians of each race provided counseling at different rates for obese patients of different races. We did not observe a positive association between patient-physician race concordance and weight-related counseling. We found that visits by black obese patients to white doctors had a lower odds of exercise counseling as compared to visits by white obese patients to white doctors (odds ratio (OR) = 0.54; 95% confidence interval (CI): 0.31, 0.95), and visits by black obese patients to black physicians had lower odds of receiving weight-reduction counseling than visits among white obese patients seeing black physicians (OR = 0.34; 95% CI: 0.13, 0.90). Black obese patients receive less exercise counseling than white obese patients in visits to white physicians and may be less likely than white obese patients to receive weight-reduction counseling in visits to black physicians.

Provision of weight management advice for obese women during pregnancy: a survey of current practice and midwives' views on future approaches

A semi-structured, web-based questionnaire was developed to survey midwives (n = 241) employed by NHS Tayside, UK, to identify current practice and views on weight management of obese women during pregnancy and the puerperium. A total of 78 (32%) midwives submitted responses following email invitation. Most respondents (79%) reported always calculating women's body mass index (BMI) at booking, with 73% routinely explaining the BMI category. In terms of future practice for obese women, although few respondents (15%) currently offer personalised advice regarding weight management based on a woman's diet and physical activity levels, 77% of respondents thought such advice would be appropriate and 69% thought it could possibly be feasible to offer such advice. The respondents viewed weight management to be of importance and felt that universal advice is appropriate, but confidence in discussing weight management and knowledge of the subject was low. Strategies to improve midwife confidence and weight management services should include training, ongoing support and definition of the midwife's role within the multidisciplinary team to support practice in the future.

Physician practice patterns of obesity diagnosis and weight-related counseling

METHODS

we analyzed cross-sectional clinical encounter data. Obese adults were obtained from the 2005 National Ambulatory Medical Care Survey (N=2458).

RESULTS

a third of obese adults received an obesity diagnosis (28.9%) and approximately a fifth received counseling for weight reduction (17.6%), diet (25.2%), or exercise (20.5%). Women (OR=1.54; 95% CI: 1.14, 2.09), young adults ages 18-29 (OR=2.61; 95% CI: 1.37, 4.97), and severely/morbidly obese individuals (class II: OR 2.08; 95% CI: 1.53, 2.83; class III: OR 4.36; 95% CI: 3.09, 6.16) were significantly more likely to receive an obesity diagnosis. One of the biggest predictors of weight-related counseling was an obesity diagnosis (weight reduction: OR=5.72; 95% CI: 4.01, 8.17; diet: OR=2.89; 95% CI: 2.05, 4.06; exercise: OR=2.54; 95% CI: 1.67, 3.85). Other predictors of weight-related counseling included seeing a cardiologist/other internal medicine specialist, a preventive visit, or spending more time with the doctor (p<0.05).

CONCLUSIONS

most obese patients do not receive an obesity diagnosis or weight-related counseling.

PRACTICE IMPLICATIONS

preventive visits may provide a key opportunity for obese patients to receive weight-related counseling from their physician.

A context-aware fitness guide system for exercise optimization in U-health

In this paper, exercise management systems have been introduced, which are generally used to optimize exercise. They create a proper exercise program via an exercise prescription based on the personal physical status of the user. However, exercise programs, generally created at intervals of two weeks to three months, are static and cannot reflect the user's exercise goals, which change dynamically. This paper proposes context-aware exercise architecture (CAEA), which provides an exercise program via a dynamic exercise prescription based on awareness of the user's status. We use sensors of a U-health environment and implement CAEA as an intelligent fitness guide (IFG) system. The IFG system selectively receives necessary parameters as input according to the user's exercise goals. Based on the changes in the user's exercise type, frequency, and intensity, the system creates an exercise program via an exercise optimization algorithm. In this paper, to show the exercise efficiency using the IFG system, we compared a noncontrol group to a control group. An eight-week study was performed comparing the changes of body weight in the two study groups. The study showed that the control group using the IFG system approached the desired body weight 2.57% more closely than the noncontrol group. Since IFG provides a real-time exercise program for users via an exercise optimization algorithm, it enables the user to perform effective and stable exercise according to the user's physical status.

Italian network for obesity and cardiovascular disease surveillance: a pilot project

Background

Also in Mediterranean countries, which are considered a low risk population for cardiovascular disease (CVD), the increase in body mass index (BMI) has become a public health priority. To evaluate the feasibility of a CVD and obesity surveillance network, forty General Practitioners (GPs) were engaged to perform a screening to assess obesity, cardiovascular risk, lifestyle habits and medication use.

Methods

A total of 1,046 women and 1,044 men aged 35–74 years were randomly selected from GPs' lists stratifying by age decade and gender. Anthropometric and blood pressure measurements were performed by GPs using standardized methodologies. BMI was computed and categorized in normal weight (BMI 18.5–24.9 kg/m²), overweight (BMI 25.0–29.9 kg/m²) and obese (BMI ≥ 30 kg/m²). Food frequency (per day: fruits and vegetables; per week: meat, cheese, fish, pulses, chocolate, fried food, sweet, wholemeal food, rotisserie food and sugar drink) and physical activity (at work and during leisure time) were investigated through a questionnaire. CVD risk was assessed using the Italian CUORE Project risk function.

Results

The percentage of missing values was very low. Prevalence of overweight was 34% in women and 50% in men; prevalence of obesity was 23% in both men and women. Level of physical activity was mostly low or very low. BMI was inversely associated with consumption of pulses, rotisserie food, chocolate, sweets and physical activity during leisure time and directly associated with consumption of meat. Mean value of total cardiovascular risk was 4% in women and 11% in men. One percent of women and 16% of men were at high cardiovascular risk (≥ 20% in 10 years). Normal weight persons were four times more likely to be at low risk than obese persons.

Conclusion

This study demonstrated the feasibility of a surveillance network of GPs in Italy focusing on obesity and other CVD risk factors. It also provided information on lifestyle habits, such as diet and physical activity.

Treatment of Overweight and Obesity in Primary Care Practice: Current Evidence and Future Directions

Obesity is commonly encountered in primary care practice. Yet many patients who are overweight or obese are not identified, and those who are do not receive adequate treatment or referral. For many primary care providers, barriers to addressing weight control with patients include lack of time, limited training and resources, patient readiness to change, and inadequate insurance reimbursement. Studies that have evaluated weight control interventions in primary care vary tremendously in design and methodology. Most studies have focused on primary care provider training or practice-level interventions, or they have combined physician and nutrition counseling. Although results from these studies are encouraging, more randomized clinical trials are needed in this area. Future avenues for study include electronic health records, computer-tailored interventions, and translation of efficacious weight control interventions into primary care settings.

State of the Art Reviews: Relationship Between Diet/ Physical Activity and Health

Obesity and 4 of the leading causes of death—heart disease, cancer, stroke, and type 2 diabetes mellitus—are related to lifestyle. The combination of a healthy weight, prudent diet, and daily physical activity clearly plays a role in primary, secondary, and tertiary prevention of these and other chronic diseases. Because nearly 65% of the adult population is overweight or obese, weight loss and maintenance are central to this review article. Improved lipid profiles, blood pressure, insulin sensitivity, and euglycemia are associated with weight loss or a normal body weight; thus, maintaining a healthy weight is a universal recommendation for health. The methods for improving lifestyle described in the section on obesity include assessing nutritional status and stages of change of the client, setting realistic goals, eating a diet high in fruits and vegetables with low-fat sources of dairy and protein, and achieving appropriate physical activity levels. The importance of physicians discussing weight with clients and vice versa is stressed. The common features of lifestyle-related diseases make them amenable to similar lifestyle interventions.

Management of obesity in primary care: nurses? practices, beliefs and attitudes

AIM

This paper is a report of a study to investigate patterns of clinical practice, beliefs and attitudes of primary care nurses with respect to obesity management.

BACKGROUND

Nurses in primary care potentially play a key role in managing obesity, which has become a priority issue. There have been few studies of either the extent of clinical practice of nurses, or their attitudes and beliefs in this setting.

METHODS

A correlational survey design was employed. Structured questionnaires were posted to 564 nurses and health visitors in primary care organizations in England. The response rate was 72.3%. The survey was conducted in April and May 2006.

FINDINGS

Very few respondents reported training in obesity management, and most did not believe that organizational support was in place. Only practice nurses reported substantial clinical activity in obesity management, accounting for almost 5% of their contracted hours. This activity, comprised of assessment, lifestyle change support and referral, occurred in one-to-one consultations. Other nurses and health visitors reported much less activity, although they believed obesity to be an important health issue and its management an appropriate part of their role. Whilst outright negative stereotypes were rare, there were nevertheless a range of potentially negative beliefs and attitudes relating to obesity and obese patients. These views were related to the respondent's own body mass index but not to gender, age, experience and occupation.

CONCLUSION

Training and organizational support for obesity management are required by primary care nurses. Training should also address beliefs and attitudes about obesity and obese persons.

The Children's Computerized Physical Activity Reporter

The objectives of this three-phased study were to design and evaluate the usability of a computerized questionnaire, The Children's Computerized Physical Activity Reporter, designed with and for middle school children's self-report of physical activity. Study design was qualitative, descriptive, and collaborative, framed in a usability engineering model, with 22 participating children (grades 6-8; mean age, 12.5 years; range, 11-15 years) of three ethnic backgrounds. In Phase 1, children's understanding of physical activity and needs for reporting were determined, which were then translated in Phase 2 to the design features and content of the questionnaire; content validity, readability, and algorithm reliability were completed. Phase 3 involved children's evaluation of the questionnaire's usability (ease of use, efficiency, and aesthetics). The children all liked the questionnaire but identified several usability issues within instructions and reports. Working collaboratively with children was highly effective in ascertaining their understanding of physical activity and their self-reporting needs. Thus, the questionnaire's design was created from children's understanding of physical activity and their needs for recalling activities. The development of the questionnaire and its usability evaluation contribute to understanding children's physical activity and to the importance of designing for usability. Additional research is needed to ascertain reliability and validity of data derived from its use and to explore its usefulness in clinical or research venues.

Smoking prevention and cessation intervention delivery by pediatric providers, as assessed with patient exit interviews

OBJECTIVE

The goal was to evaluate the degree to which a smoking prevention and cessation intervention was delivered by providers to adolescents in the pediatric office setting.

METHODS

Eight pediatric clinics in central Massachusetts were assigned randomly to either a special intervention (brief pediatric provider-delivered intervention plus peer counseling) or the usual care condition. Subjects (n = 2710) were adolescents 13 to 17 years of age, both smokers (smoked in the past 30 days) and nonsmokers/former smokers. The degree to which smoking prevention and treatment interventions were delivered by providers was assessed through patient exit interviews with adolescents after their clinic visits; interviews assessed the occurrence of 10 possible intervention steps.

RESULTS

The percentage of providers engaging in the smoking interventions differed significantly between the special intervention and usual care conditions, according to adolescent reports in the patient exit interviews. For nonsmokers/former smokers, overall patient exit interview scores were 7.24 for the special intervention condition and 4.95 for the usual care condition. For current smokers, overall patient exit interview scores were 8.40 and 6.24 for the special intervention and usual care conditions, respectively. Intervention fidelity of special intervention providers was 72.2% and 84.0% for nonsmokers/former smokers and current smokers, respectively.

CONCLUSIONS

Pediatric providers who receive training and reminders to deliver a brief smoking prevention and cessation intervention to adolescents in the context of routine pediatric primary care practice can do so feasibly and with a high degree of fidelity to the intervention protocol.

Barriers to obesity management: a pilot study of primary care clinicians

Background

Obesity is an increasing epidemic in both the US and veteran populations, yet it remains largely understudied in the Veteran's Health Administration (VHA) setting. The purpose of our study was to identify barriers to the effective management of obesity in VHA primary care settings.

Methods

Three focus groups of clinicians from a Veteran's Affairs Medical Center (VAMC) and an affiliated Community Based Outpatient Center (CBOC) were conducted to identify potential barriers to obesity management. The focus groups and previously published studies then informed the creation of a 47-item survey that was then disseminated and completed by 55 primary care clinicians.

Results

The focus groups identified provider, system, and patient barriers to obesity care. Lack of obesity training during medical school and residency was associated with lower rates of discussing diet and exercise with obese patients (p < 0.05). Clinicians who watched their own diets vigorously were more likely to calculate BMI for obese patients than other clinicians (42% vs. 13%, p < 0.05). Many barriers identified in previous studies (e.g., attitudes toward obese patients, lack of insurance payments for obesity care) were not prevalent barriers in the current study.

Conclusion

Many VHA clinicians do not routinely provide weight management services for obese patients. The most prevalent barriers to obesity care were poor education during medical school and residency and the lack of information provided by the VHA to both clinicians and patients about available weight management services.

Management of overweight and obesity in adults: behavioral intervention for long-term weight loss and maintenance

BACKGROUND

The World Health Organization has identified obesity as a global epidemic. While weight loss is a considerable challenge, long-term maintenance of weight loss is an even greater problem.

AIMS

This review of the assessment and management of overweight and obesity in adults covers factors contributing to overweight and obesity, components of weight-loss management, and interventions and effects of behavioral treatment for long-term weight loss and maintenance.

METHODS

A thorough search of the medical and nursing literature recorded in the MEDLINE database from 1995 to 2003 was conducted by using the keywords "overweight", "obesity", and "behavioral therapy".

RESULTS

Obesity is a complex, multifaceted condition in which excessive body fat places a person at risk of multiple health problems. Excessive body fat results from energy intake that exceeds energy expenditure.

CONCLUSIONS

Increasing evidence suggests that obesity is not simply a problem of will power or self-control but a complex disorder involving appetite regulation and energy metabolism that is associated with a variety of comorbid conditions. Effective strategies of weight loss require management strategies in a combined approach of dietary therapy and physical activity by using behavioral interventions.

Industry-Sponsored Weight Loss Programs: Description, Cost, and Effectiveness

PURPOSE

To describe three commercial weight loss programs (Jenny Craig, LA Weight Loss, and Weight Watchers), including efficacy data when available, and to provide clinicians with information for patient counseling.

DATA SOURCES

Personal interviews, journal articles, and Web site information.

CONCLUSIONS

Commercial weight loss programs provide weight loss services. Benefits are experience, planned menus, and psychological support. Limitations are cost, sales promotions that encourage on-the-spot commitment to prepaid contracts, and the cost of program food and additional vitamins.

IMPLICATIONS FOR PRACTICE

Weight loss is a necessary goal for many patients. Clinicians are mandated to provide counseling regarding weight loss.

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

BACKGROUND

To analyze whether internists are suited for their role in treating the growing numbers of obese patients, we surveyed residents about their knowledge and attitudes regarding obesity. Previous assessments have not analyzed familiarity with obesity measurement tools or the correlation between knowledge and attitudes.

METHODS

We administered a survey to 87 internal medicine residents in two urban, university-based residency programs.

RESULTS

Almost all respondents understood the medical consequences of obesity, but 60% did not know the minimum BMI for diagnosing obesity, 69% did not recognize waist circumference as a reasonable measure of obesity, and 39% incorrectly reported their own BMI. Although nearly all respondents agreed that treating obesity was important, only 30% reported treatment success. Forty-four percent felt qualified to treat obese patients, and 31% reported treatment to be futile. Knowledge and attitudes were not correlated. Rasch analysis of knowledge and attitude subscales showed satisfactory model fit and item reliability of at least 0.96.

CONCLUSIONS

Despite solid knowledge of the comorbid conditions associated with obesity, residents have a poor grasp of the tools necessary to identify obesity. They also have negative opinions about their skills for treating obese patients. Residency training not only must improve knowledge of obesity measurement tools but also must address physicians' negative attitudes toward obesity treatment.

Assessing physical activity in adolescents: common activities of children in 6th-8th grades

OBJECTIVES

To provide data for physical activity assessment in practice by describing the leisure time activities of adolescents and determining if the activities and the metabolic equivalents (MET levels) of those activities differ for boys and girls.

DATA SOURCES

The study was conducted in five middle schools in three rural counties in North Carolina. Subjects were 1,211 6th, 7th, and 8th graders aged 11-14 (mean 12.2) years. Half (52.5%) were girls. The sample was 64% white, 24% African-American and 12% other races.

RESULTS

The top five activities of boys were football, basketball, bicycling, running, and baseball; the top five activities of girls were talking, running, walking, bicycling, and dancing. The average MET was 5.3 for boys and 4.3 for girls (p = 0.000). By grade levels, 6th graders had an average MET of 4.9 and the MET of 8th graders was 4.5 (p < 0.05). Older youth, girls, and children of parents with more education reported significantly more sedentary activities than the other youth.

IMPLICATIONS FOR PRACTICE

Physical activity is an integral component of overall health. Once activities and activity levels are known, current practices can be augmented or changed to accommodate improved understanding of physical activity. Because an active lifestyle is important in preventing obesity and other chronic conditions and for general health, nurse practitioners (NPs) should ask adolescents about their common activities and encourage them to continue the more vigorous activities and reduce time spent in sedentary pursuits. Prescriptive physical activity can be included for primary, secondary, or even tertiary prevention, thus crossing all levels of NP practice.

Fostering prevention in the pediatric population

Although cardiovascular disease is seldom manifested clinically before the fourth or fifth decade of life, atherosclerotic cardiovascular disease processes begin in early childhood. Fatty streaks and atherosclerotic lesions have been found post-mortem in the aorta and coronary vessels of children as young as 6 years of age. The modifiable risk factors for heart and vascular disease that are found in adults, such as hypertension, dyslipidemia, smoking, obesity, and physical inactivity, are also present in children. Available evidence emphasizes the need for both population-based and individual approaches to primary prevention of CVD beginning in childhood. This article summarizes this evidence and outlines strategies for promoting primary prevention in children and adolescents.