Obesity management in primary care: assessment of readiness to change among 284 family practice patients

Mental and Physical Readiness for Weight Loss After Abdominal Organ Transplant

INTRODUCTION

Readiness to incorporate healthy lifestyle practices is not studied in posttransplant patients. We evaluate physical and mental readiness for a weight-loss guided lifestyle intervention.

METHODS

12 kidney and 12 liver transplant patients were given a Fitbit and weighing scale for 12 mo. Twelve patients received group sessions on lifestyle modifications. Mental readiness was assessed using Patient Activation Measurement-13, Physical Activity, Process of Change, and Weight Stages of Change. Physical readiness was assessed using Fatigue, Resistance, Ambulation, Illness, and Loss of Weight, and Short Physical Performance Battery questionnaires. Weight change, group session attendance, device usage, and readiness were analyzed.

RESULTS

23 patients (12 kidney, 11 liver), 57 y (46.2-67.5), 75% male, 24.9 (15.7-43.2) months posttransplant) completed the study. Twenty-two patients had robust physical readiness, and high Fitbit usage (>80%). Ten patients (43%) lost ≥2.5% (moderate) of body weight, including 4 (17.3%) losing >5% total weight (high). 13 patients lost ≤2.5% or gained weight (maintenance). High loss and target group session attendance groups had the highest use of Processes of Change.

CONCLUSIONS

Posttransplant patients are physically ready for a weight-loss guided lifestyle intervention and show high usage of the Fitbit device. Higher mental readiness associates with higher weight loss.

Why do some people with osteoarthritis and obesity awaiting hip or knee arthroplasty achieve successful weight management? A qualitative study

AIM

To explore perceived barriers and enablers to weight management among people with obesity awaiting total knee or hip arthroplasty.

DESIGN

A nested qualitative study within a multi-centre, quasi-experimental pilot study comparing usual care weight management to a dietitian-led weight-loss diet.

METHODS

Semi-structured individual interviews were conducted with adults with end-stage osteoarthritis and a body mass index ≥30 kg/m2 waitlisted for primary total knee or hip arthroplasty. Participants with diverse sociodemographic characteristics and varied success with weight management in the pilot study were purposively sampled. Interviews were analysed using inductive thematic analysis, underpinned by constructivist-interpretivist epistemology. The Patient Activation Measure and Health Literacy Questionnaire were used for context when interpreting the findings.

RESULTS

Twenty-five participant interviews were conducted with a sociodemographically varied sample (aged 44-80 years, 9 born in Australia, 6 in paid employment and 11 lost ≥5% of their baseline weight). Four identified themes underpinned successful weight management: beliefs, adaptability, navigating healthcare and sociocultural context. Beliefs about whether weight was perceived as a problem, the expectation of weight loss and treatment-related beliefs influenced participants' perspectives towards weight loss. Adaptability, the ability to overcome barriers to weight loss, comprised three subthemes; readiness to act, degree of independence and problem-solving skills. Approaches towards navigating healthcare influenced uptake and adherence to weight management recommendations. Importantly, these themes were dependent on social and environmental circumstances, which influenced the type of barriers experienced and resources available to the individual.

CONCLUSION

Differences in a person's beliefs, their ability to adapt and navigate healthcare and sociocultural context appear to explain successful weight management among people with end-stage arthritis.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Clinicians should allow for individualisation cognisant of the identified themes when providing advice and treatment to promote adherence to weight management interventions.

IMPACT

This study explored perceived barriers and enablers to weight management among people with obesity awaiting total knee or hip arthroplasty. Four identified themes underpinned successful weight management: beliefs, adaptability, navigating healthcare and sociocultural context. Beliefs about whether weight was perceived as a problem, the expectation of weight loss and treatment-related beliefs influenced participants' perspectives towards weight loss. Understanding and assessing the contribution of each factor may guide weight management from clinicians treating patients with obesity and osteoarthritis.

REPORTING METHOD

The data are reported using the COREQ guidelines.

PATIENT OR PUBLIC CONTRIBUTION

Patients contributed to the data collected.

Gaps in Referral to Bariatric Surgery for Patients With Type 2 Diabetes Seen in Endocrinology Clinics

OBJECTIVES

One-third of adults in Canada are overweight and 26.8% experience obesity. Bariatric surgery confers effective weight loss and reduces obesity-related complications, including type 2 diabetes, but remains an underutilized treatment. Our objective in this study was to determine whether a gap exists in bariatric program referrals for patients with type 2 diabetes seen in endocrinology clinics at an ambulatory tertiary care hospital in Toronto, Canada.

METHODS

A retrospective chart review was conducted of 843 consecutive patients with type 2 diabetes in endocrinology clinics between January 1, 2015 and December 31, 2020. Inclusion criteria were age ≥18 years, type 2 diabetes and body mass index (BMI)>35 kg/m². Exclusion criteria were recent active cancer, uncontrolled psychiatric disease or active substance use disorder within 6 months of the initial visit. Referrals to bariatric surgery were assessed within a 5-year follow-up period and compared with baseline referral rates from the Ontario Bariatric Network (OBN). An online survey of 48 endocrinologists in Toronto, Ontario, was also conducted to assess physician-level barriers to referral.

RESULTS

The proportion of patients with class II obesity (BMI>35 kg/m²) and type 2 diabetes meeting the eligibility criteria for bariatric referral was 4.6% (n=38). A documented discussion about bariatric surgery occurred with 7 (18.0%) of these eligible patients, and 1 patient (2.6%) was referred for surgery. Aside from surgical referrals, only 2.6% of eligible patients were referred to cognitive-behavioural therapy, 36.8% were initiated on obesity pharmacotherapy and 42.1% were referred to a dietitian. Baseline OBN data demonstrated that most surgical referrals (n=6,360) were from family physicians (65.0%) and only 8.8% were from a medical specialist. Eight percent of surveyed endocrinologists reported that they discussed bariatric surgery with at least half of their eligible patients. The most frequent barrier to discussing bariatric surgery during visits was time constraints. Physicians identified that simplifying the referral process and providing bariatric surgery handouts would be helpful interventions to improve referral rates.

CONCLUSIONS

Our gap analysis demonstrated a low bariatric surgery referral rate by tertiary care endocrinologists. Our study also identified a large gap in the appropriate treatment of obesity with poor utilization of behavioural, lifestyle and pharmacotherapy practices. As obesity and diabetes rates increase, better education, training and knowledge translation will be necessary to overcome weight bias and prioritize obesity management.

Turkish primary care physicians’ attitudes and knowledge of obesity and bariatric surgery: a survey study

Objective: This survey study attempted to determine Turkish primary care physicians’ (PCP) knowledge, attitudes, and perceptions of obesity treatment and bariatric surgery. Moreover, the relationship between the duration of practice as a physician, and especially the indications for bariatric surgery and referral to surgery were investigated.

Material and Methods: A survey of 27 questions was administered via social media and the internet using the SurveyMonkey platform. The physicians who responded to the survey were grouped based on the duration of working life. Among these groups, the responses to the questions about bariatric surgery were compared using univariate analysis.

Results: A total of 1044 physicians responded to the survey. The number of physicians who strongly agreed that a PCP should play role in the treatment of obesity was 743 (71.1%). The most important reason for not undertaking this treatment was reported as the requirement for a multidisciplinary approach to obesity treatment (51.5%, n= 537). The percentage of those who thought that patients with a body mass index (BMI) above 40 kg/m2 should be referred to surgery was 72.3%,while the percentage of those referring patients with a BMI of 35-40 kg/m2 and comorbidities to surgery was 53.3%, and the percentage of those referring patients with a BMI of 35-40 kg/m2 and uncontrolled diabetes to surgery was 35.9%. Physicians who were new to the profession were found to evaluate surgical indications more positively (p< 0.05).

Conclusion: This study found that PCPs in Turkey had a basic knowledge of obesity treatment and were willing to treat and follow up these patients. However, it was observed that they could not adequately focus on this issue due to the requirement for a multidisciplinary approach to the disease and the workload. It was found that the young physiciansð level of knowledge of bariatric surgery was higher, but their attitudes towards patient referral were similar.

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.

Creating a measure of portion control self-efficacy

OBJECTIVE

Over the last few decades, food portion sizes have steadily increased by as much as 700% (Young & Nestle, 2002). Food portions are often much larger than dietary guidelines recommend, leaving individuals to manage their food consumption on their own and making it necessary to understand individual factors impacting food consumption. In the current paper, we focus on self-efficacy for portion control.

METHOD

Specifically, across three studies, we developed and validated a new measure of portion control self-efficacy (PCSE).

RESULT

The PCSE measure yielded good fit statistics and had acceptable test-retest reliability using two cross-sectional surveys (Studies 1(a) and 1(b)). Results from Study 2 demonstrated construct and predictive validity of the PCSE using the Food Amount Rating Scale (FARS; Dohm, & Striegel-Moore, 2002). Study 3 offered additional support for reliability and validity with a sample of overweight and obese adults currently trying to lose weight.

CONCLUSIONS

Overall, findings indicate that the new PCSE measure is reliable and valid. Individuals often make inaccurate food portion estimates (Slawson & Eck, 1997; Yuhas, Bolland, & Bolland, 1989) which can lead to overeating and weight-gain. Thus, the discussion centers on the need to incorporate PCSE in future research and intervention work targeting weight loss, health, and food consumption.

Readiness for diabetes prevention and barriers to lifestyle change in women with a history of gestational diabetes mellitus: rationale and study design

AIMS

Women with gestational diabetes mellitus (GDM) have a high risk of future diabetes, which can be prevented with lifestyle modification. Prior diabetes prevention programmes in this population have been limited by lack of adherence. The aim of this study is to evaluate readiness for behaviour change at different time points after GDM diagnosis and identify barriers and facilitators, to inform a lifestyle modification programme specifically designed for this group. The objective of this paper is to present the rationale and methodological design of this study.

METHODS

The ongoing prospective cohort study has recruited a multi-ethnic cohort of 1353 women with GDM from 7 Ontario, Canada hospitals during their pregnancy. A questionnaire was developed to evaluate stage of readiness for behaviour change, and sociodemographic, psychosocial, and clinical predictors of healthy diet and physical activity. Thus far, 960 women (71%) have completed a baseline survey prior to delivery. Prospective postpartum follow-up is ongoing. We are surveying women at 2 time-points after delivery: 3-12 months postpartum, and 13-24 months postpartum. Survey data will be linked to health care administrative databases for long-term follow-up for diabetes. Qualitative interviews were conducted in a subset of women to gain a deeper understanding of barriers and facilitators to lifestyle change.

CONCLUSIONS

Our study is a fundamental first step in effectively addressing diabetes prevention in women with GDM. Our findings will aid in the design of a diabetes prevention intervention specifically targeted to women with recent GDM, which can then be evaluated in a clinical trial.

Assessing Readiness to Lose Weight among Obese Women Attending the Nutrition Clinic

BACKGROUND

Assessing individual's readiness to change and targeting the inter-vention to the level of readiness may improve successful weight loss rates. This study aimed to assess readiness for weight loss in obese women using the trans theoretical model.

METHODS

A cross-sectional study was conducted on 90 volunteer apparently healthy obese women, in Ardabil, Iran. Participants completed the translated and validated University of Rhode Island Change Assessment questionnaire in their first visit. Subjects were categorized into one of the stages of change based on the highest of four z-transformed scale scores. The readiness to change score was calculated.

RESULTS

More than half of the participants were in early stages of weight loss and 24.5% were in the action stage. The readiness score in the precontemplation stage was significantly lower than the other stages, but no significant difference was observed among the contemplation, action and maintenance stages. The significant correlation was observed between the stages of change and waist-to-hip ratio (r=0.33, P<0.05).

CONCLUSION

Obese women attending the nutrition clinic are in different stages to change for weight loss. Understanding person specific stages of change ori-entates the dietitian to use the most appropriate counseling strategies. Hence the stages and readiness to change should be considered before implementing any intervention in clinical settings for optimal outcomes.

The transtheoretical model as applied to dietary behaviour and outcomes

The transtheoretical model (TTM) is a behavioural theory that describes behaviour change as occurring in five stages, ranging from precontemplation to maintenance. The purpose of the present paper is to review and synthesise the literature published since 1999 on applications of the TTM to dietary behaviour so that the evidence for the use of assessment tools and interventions based on this model might be evaluated. Six databases were identified and searched using combinations of key words. Sixty-five original, peer-reviewed studies were identified and summarised in one of three tables using the following categories: population (n 21), intervention (n 25) and validation (n 19). Internal validity ratings were given to each intervention, and the body of intervention studies as a whole was rated. The evidence for using stage-based interventions is rated as suggestive in the areas of fruit and vegetable consumption and dietary fat reduction. Valid and reliable staging algorithms are available for fruit and vegetable consumption and dietary fat intake, and are being developed for other dietary behaviours. Few assessment tools have been developed for other TTM constructs. Given the popularity of TTM-based assessments and interventions, more research is warranted to identify valid and reliable assessment tools and effective interventions. While the evidence supports the validity of the TTM to describe populations and to form interventions, evidence of the effectiveness of TTM-based interventions is not conclusive.

Transtheoretical Model-Chronic Disease Care for Obesity in Primary Care: A Randomized Trial

OBJECTIVE

To compare health benefits achieved in a transtheoretical model-chronic disease (TM-CD) minimal intervention for obesity vs. augmented usual care (AUC).

RESEARCH METHOD AND PROCEDURES

This was a 2-year, randomized clinical trial with overweight or obese men and women from 15 primary care sites. AUC (n = 336) included dietary and exercise advice, prescriptions, and three 24-hour dietary recalls every 6 months. TM-CD care (n = 329) included AUC elements plus "stage of change" (SOC) assessments for five target behaviors every other month, mailed SOC and target behavior-matched workbooks, and monthly telephone calls from a weight-loss advisor. Weight change was the primary outcome.

RESULTS

Repeated measures models under the missing at random assumption yielded nonsignificant adjusted differences between the AUC and TM-CD groups for weight change, waist circumference, energy intake or expenditure, blood pressure, and blood lipids. The pattern of change over time suggested that TM-CD participants were trying harder to impact target behaviors during the first 6 to 12 months of the trial but relapsed afterward. Sixty percent of trial participants maintained their baseline weights for 18 to 24 months.

DISCUSSION

A combination of mailed patient materials and monthly telephone calls based on the transtheoretical model and some elements of chronic disease care is not powerful enough, relative to AUC, to alter target behaviors among overweight primary care patients in an obesogenic environment. AUC may be sufficient to maintain weights among at-risk primary care patients.

Longitudinal Relationship between Elapsed Time in the Action Stages of Change and Weight Loss

OBJECTIVE

The objective of this study was to examine the longitudinal relationship between the elapsed time in the action and maintenance stages of change for multiple target behaviors and weight loss or gain.

RESEARCH METHODS AND PROCEDURES

The research design was a prospective cohort study of overweight and obese primary care patients randomized to an obesity management intervention based on the Transtheoretical Model and a chronic disease paradigm. The target behaviors included increased planned exercise and usual physical activity, decreased dietary fat, increased fruit and vegetable consumption, and increased dietary portion control. The participants were 329 middle-aged men and women with elevated body mass indices recruited from 15 primary care practices in Northeastern Ohio; 28% of the participants were African Americans. The main outcomes were weight loss (5% or more) or weight gain (5% or more) after 18 or 24 months of follow-up.

RESULTS

There were significant (p < 0.05) longitudinal relationships between the number of periods (0 to 4) in action or maintenance for each of the five target behaviors, or a composite score taken across the five target behaviors, and weight loss. In all cases, there was a significant (p < 0.05) stepped (graded) relationship between the time in action or maintenance and weight loss (or gain).

DISCUSSION

The data support the concept of applying the Transtheoretical Model to the problem of managing obesity in primary care settings. The remaining challenge is to identify those factors that reliably move patients into the action and maintenance stages for long periods.

Therapeutic benefit of preventive telehealth counseling in the Community Outreach Heart Health and Risk Reduction Trial

We evaluated whether telehealth counseling augments lifestyle change and risk factor decrease in subjects at high risk for primary or secondary cardiovascular events compared to a recommended guideline for brief preventive counseling. Subjects at high risk or with coronary heart disease (35 to 74 years of age, n = 680) were randomized to active control (risk factor feedback, brief advice, handouts) or telehealth lifestyle counseling (active control plus 6 weekly 1-hour teleconferenced sessions to groups of 4 to 8 subjects). Primary outcome was questionnaire assessment of adherence to daily exercise/physical activity and diet (daily vegetable and fruit intake and restriction of fat and salt) after treatment and at 6-month follow-up. Secondary outcomes were systolic and diastolic blood pressures, ratio of total to high-density lipoprotein cholesterol, and 10-year absolute risk for coronary disease. After treatment and at 6-month follow-up, adherence increased for telehealth versus control in exercise (29.3% and 18.4% vs 2.5% and 9.3%, respectively, odds ratio 1.60, 95% confidence interval 1.2 to 2.1) and diet (37.1% and 38.1% vs 16.7% and 33.3%, respectively, odds ratio 1.41, 95% confidence interval 1.1 to 1.9). Telehealth versus control had greater 6-month decreases in blood pressure (mean ± SE, systolic -4.8 ± 0.8 vs -2.8 ± 0.9 mm Hg, p = 0.04; diastolic -2.7 ± 0.5 vs -1.5 ± 0.6 mm Hg, p = 0.04). Decreases in cholesterol ratio and 10-year absolute risk were significant for the 2 groups. In conclusion, telehealth counseling augments therapeutic lifestyle change in subjects at high risk for cardiovascular events compared to a recommended guideline for brief preventive counseling.

Counseling overweight in primary care: an analysis of patient-physician encounters

OBJECTIVE

The aim of this study was to assess general practitioners' (GPs') and patients' practices and attitudes regarding overweight encountered during preventive counseling talks.

METHODS

Twelve GPs audiotaped their preventive counseling talks with overweight patients, including the assessment of individual risk profiles and further medical recommendations. Fifty-two dialogues were transcribed and submitted to qualitative content analysis.

RESULTS

Dietary advice and increased physical activity are mostly discussed during talks. Recommendations appear to be more individual if patients are given the chance to reflect on causes of their overweight during counseling talks.

CONCLUSIONS

A dialogue approach affects the strength and quality of weight loss counseling in primary care. However, physicians and overweight patients rarely agreed on weight loss goals during the physician-patient talks.

PRACTICAL IMPLICATIONS

Patient centeredness, particularly the integration of patients' perceptions towards weight management, might be an important step towards improving weight counseling in primary care.

The role of the General Practitioner in weight management in primary care--a cross sectional study in General Practice

Background

Obesity has become a global pandemic, considered the sixth leading cause of mortality by the WHO. As gatekeepers to the health system, General Practitioners are placed in an ideal position to manage obesity. Yet, very few consultations address weight management. This study aims to explore reasons why patients attending General Practice appointments are not engaging with their General Practitioner (GP) for weight management and their perception of the role of the GP in managing their weight.

Methods

In February 2006, 367 participants aged between 17 and 64 were recruited from three General Practices in Melbourne to complete a waiting room self – administered questionnaire. Questions included basic demographics, the role of the GP in weight management, the likelihood of bringing up weight management with their GP and reasons why they would not, and their nominated ideal person to consult for weight management. Physical measurements to determine weight status were then completed. The statistical methods included means and standard deviations to summarise continuous variables such as weight and height. Sub groups of weight and questionnaire answers were analysed using the χ² test of significant differences taking p as < 0.05.

Results

The population sample had similar obesity co-morbidity rates to the National Heart Foundation data. 74% of patients were not likely to bring up weight management when they visit their GP. Negative reasons were time limitation on both the patient's and doctor's part and the doctor lacking experience. The GP was the least likely person to tell a patient to lose weight after partner, family and friends. Of the 14% that had been told by their GP to lose weight, 90% had cardiovascular obesity related co-morbidities. GPs (15%) were 4th in the list of ideal persons to manage weight after personal trainer

Conclusion

Patients do not have confidence in their GPs for weight management, preferring other health professionals who may lack evidence based training. Concurrently, GPs target only those with obesity related co-morbidities. Further studies evaluating GPs' opinions about weight management, effective strategies that can be implemented in primary care and the co-ordination of the team approach need to be done.

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.

Evaluation of a primary care-oriented brief counselling intervention for obesity with and without orlistat

OBJECTIVE

There is a significant need for an obesity treatment model suitable for the primary care environment. We examined the effectiveness of a brief counselling intervention alone, in combination with orlistat, and drug-alone in a 12-month randomized-clinical trial at a medical school obesity centre.

METHODS

Participants (N = 250) with body mass index (BMI) >or=27 were randomized. Changes in body weight, lipids, blood pressure and serum glucose were examined. Drug adherence and attendance were also evaluated.

RESULTS

Completers analysis was conducted on 136 participants with data at baseline, 6 and 12 months and intention-to-treat analyses (ITT) for the total sample. Amongst completers, participants in the drug only (P = 0.012) and drug + brief counselling (P = 0.001) groups lost more weight (mean +/- SD: -3.8 +/- 5.8 kg and -4.8 +/- 4.4 kg, respectively) than participants in the brief counselling only group at 6 months (-1.7 +/- 3.3 kg), but there were no significant group differences at 12 months. ITT model results were similar to completers at 6 months and remained significant at 12 months, but the weight losses were more modest (<3 kg) for both groups receiving orlistat. For brief counselling alone, participants gained weight (1.7 +/- 4.2 kg). Cardiovascular disease (CVD) parameter changes were negligible.

CONCLUSIONS

Pharmacotherapy alone or combined with brief counselling resulted in modest weight losses that had minimal impact on cardiovascular parameters, but were greater than brief counselling alone. Whilst brief interventions and primary pharmacotherapy have been suggested as viable treatments for implementation in primary care settings, our study suggests that such minimal interventions provide minimal benefits.

Applying the transtheoretical model to exercise: a systematic and comprehensive review of the literature

Three questions guided a literature review of the transtheoretical model (TTM) as applied to exercise to address the evidence for stage-matched interventions, the description of priority populations, and the identification of valid TTM measurement tools. One-hundredand-fifty studies were reviewed. Results indicate preliminary support for the use of stage-matched exercise interventions. Most studies have focused on White, middle-class, female populations, limiting the generalizability of their findings. Valid and reliable measures exist for stage of change, decisional balance, processes of change, self-efficacy, and temptations to not exercise; however, more research is needed to refine these measures. Evidence for the construct validity of the TTM as applied to exercise is mixed. When designing and implementing TTM-based exercise interventions, practitioners and policy makers are encouraged to clearly define the term exercise, choose a valid and reliable staging tool, and employ all TTM constructs and not just stage membership.

Obesity management: attitudes and practices of French general practitioners in a region of France

OBJECTIVES

To document the attitudes and practices of French general practitioners (GPs) regarding obesity management.

RESEARCH METHODS AND PROCEDURES

A cross-sectional survey of a randomly selected sample of 744 French GPs was conducted, of which 607 questionnaires were returned. The measures included views on weight management, definitions of success, approaches to and strategies recommended for weight management and prevention, problems, frustrations, and expectations in managing obesity.

RESULTS

GPs have a high awareness of obesity as a medically relevant issue, with 90% of them considering it to be a disease. However, they are only 42% to consider themselves well prepared to manage obesity and 51% to find obesity management professionally rewarding. They are 66% to believe that only a small percentage of patients can lose weight and maintain that loss but have unrealistic goals, with only 20% of them considering weight maintenance as a success. They do not consider collaboration with other health professionals like dietitians as a priority. Only 34% of the GPs believe that the currently available drugs are effective. Their views regarding bariatric surgery are in agreement with the recommendations of international experts. Their main expectations regarding obesity management are to improve their professional intervention through formation, education and easy-to-use tools, rather than improving their collaboration with other health professionals.

DISCUSSION

There remains considerable opportunity to improve GPs' practice in obesity management. Medical education, increased cooperation with dietitians, improved long-term follow-up, and implementing better use of the available documents are key issues.

Stage of readiness to control weight and adopt weight control behaviors in primary care

BACKGROUND

While the majority of adults are attempting weight loss at any given time, few engage in optimal diet and exercise. We examined factors associated with being in advanced stages of behavior change for weight loss, diet, and exercise.

METHODS

We surveyed primary care patients about their health, health habits, and perception and advice about weight as health risk, and about stage of readiness to lose weight, improve diet (control food portions, limit fat intake, increase fruits and vegetables), and increase planned exercise using the Prochaska Stage of Behavior Change model. We conducted bivariable analyses to describe the association between being at the preparation (change in 1 month), action (changing now), and maintenance (maintaining change) stages of change for weight loss and being at 1 of these 3 advanced stages for improving diet and exercise. We also conducted multivariable analyses to examine factors associated with being at these advanced stages of readiness to concurrently lose weight, improve diet, and increase exercise.

RESULTS

Of 365 patients (response rate of 60%), 33% were overweight (body mass index [BMI], 25.0-29.9 kg/m(2)) and 27% were obese (BMI, 30.0+kg/m(2)). Of 199 respondents at the preparation, action, or maintenance stage of losing weight, 61% were also at an advanced stage for improving diet and exercise. Those perceiving weight as a health risk were more likely to be at advanced stages of readiness to concurrently lose weight, improve diet, and increase exercise (adjusted odds ratio [AOR], 5.6; 95% CI, 2.5 to 12.5) after adjustment for confounders; this perception was associated with BMI ([AOR, 1.2; 95% CI, 1.1 to 1.3 for each unit increment in BMI]) and being advised by a physician about weight as a health risk (AOR, 6.7; 95% CI, 3.0 to 15.1). Demographic factors, having obesity-related comorbidities, and mental and physical functioning did not appear important.

CONCLUSIONS

A large proportion of primary care patients are at advanced stages of readiness to lose weight, improve diet, and increase exercise. Future studies should examine the effectiveness of primary care interventions to help patients optimize weight-related behavior.

Effect of a Low-Cost Intervention on Recording Body Mass Index in Patients' Records

PURPOSE

Evaluate the effectiveness of body mass index (BMI) tables placed in exam rooms as an intervention to encourage providers to calculate and record BMI scores in patients' medical records.

DESIGN

In a prospective cohort design, medical record data for 276 adult patients at a federally funded community health center in New England were examined from August 2000 to August 2002 following the intervention.

METHODS

Prominent, multicolored, laminated BMI tables were posted in the exam rooms of one of the study site's three primary health care teams. Medical record data collected included documentation of BMI calculation in medical records, documentation of an obesity diagnosis, and inclusion of heights and current weights. Frequency distributions were calculated; chi-square tests were used to identify associations.

FINDINGS

In contrast to the comparison teams, patients on the intervention team were more likely to have BMI recorded in the medical record. A statistically significant increase in the diagnosis of obesity was observed throughout the health center after the intervention.

CONCLUSIONS

Posting BMI tables in exam rooms contributed to increased BMI documentation in patients' medical records.

Stages of change for weight management in postpartum women

OBJECTIVE

This study examined factors related to stages of change for weight-management behaviors in postpartum women.

DESIGN

Cross-sectional data, collected at baseline, are reported from the Mothers' Overweight Management Study (MOMS), a randomized, controlled trial conducted in postpartum women who participated in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC).Subjects/Setting Subjects were a sample of WIC recipients (N=151) older than 18 years of age with a child younger than 2 years. Statistical analysis The dependent variables were the stages of change for weight-management behaviors (losing weight, avoiding high-fat foods, eating a high-fiber diet, and exercising). Demographic, health, and psychosocial variables were examined as independent variables. One-way analysis of variance was used to compare means, and chi(2) was used for proportions.

RESULTS

Whereas 55% of women were in the action stage for weight loss, fewer women were in the action stage for the following weight management behaviors: avoiding high-fat foods (24%), increasing fiber (19%), and exercising three times per week (29%). Identifying pros for weight management was related to stages for losing weight, high-fat food avoidance, and exercise (F=13.4, P<.001; F=10.5, P<.001; F=3.7, P<.007, respectively). Self-efficacy for choosing a low-fat restaurant meal or using food labels was positively related to later stages for avoiding high-fat foods and increasing fiber intake (chi(2)=16.4, P=.003; chi(2)=11.7, P=.02).

CONCLUSIONS

Emphasizing the pros for weight-management behaviors, decreasing the cons for exercising, increasing confidence to select low-fat restaurant choices, and improving skills for using food labels are four strategies that nutrition professionals can use to help women become more ready to change behaviors for weight management.

A new evidence-based model for weight management in primary care: the Counterweight Programme

BACKGROUND/AIMS

Obesity has become a global epidemic, and a major preventable cause of morbidity and mortality. Management strategies and treatment protocols are however poorly developed and evaluated. The aim of the Counterweight Programme is to develop an evidence-based model for the management of obesity in primary care.

METHODS

The Counterweight Programme is based on the theoretical model of Evidence-Based Quality Assessment aimed at improving the management of obese adults (18-75 years) in primary care. The model consists of four phases: (1) practice audit and needs assessment, (2) practice support and training, (3) practice nurse-led patient intervention, and (4) evaluation. Patient intervention consisted of screening and treatment pathways incorporating evidence-based approaches, including patient-centred goal setting, prescribed eating plans, a group programme, physical activity and behavioural approaches, anti-obesity medication and weight maintenance strategies. Weight Management Advisers who are specialist obesity dietitians facilitated programme implementation. Eighty practices were recruited of which 18 practices were randomized to act as controls and receive deferred intervention 2 years after the initial audit.

RESULTS

By February 2004, 58 of the 62 (93.5%) intervention practices had been trained to run the intervention programme, 47 (75.8%) practices were active in implementing the model and 1256 patients had been recruited (74% female, 26% male, mean age 50.6 years, SD 14). At baseline, 75% of patients had at one or more co-morbidity, and the mean body mass index (BMI) was 36.9 kg/m(2) (SD 5.4). Of the 1256 patients recruited, 91% received one of the core lifestyle interventions in the first 12 months. For all patients followed up at 12 months, 34% achieved a clinical meaningful weight loss of 5% or more. A total of 51% of patients were classed as compliant in that they attended the required level of appointments in 3, 6, and 12 months. For fully compliant patients, weight loss improved with 43% achieving a weight loss of 5% or more at 12 months.

CONCLUSION

The Counterweight Programme is an evidence-based weight management model which is feasible to implement in primary care.

Physicians' weight loss counseling in two public hospital primary care clinics

PURPOSE

Primary care physicians are an important source of information on weight management. Nevertheless, weight loss counseling by these physicians remains inadequate. This study sought to determine physicians' barriers to providing weight loss counseling in a public hospital, patients' recall of physicians' weight loss recommendations, and the influence of physicians' counseling on patients' understanding, motivation, and behavior regarding weight loss.

METHOD

In 2001, four focus groups of faculty and residents were held at two primary care clinics affiliated with the Louisiana State University Health Sciences Center-Shreveport to determine the barriers to providing weight loss counseling. Scripted probes were used to uncover consensus norms. In 2001-02, structured exit interviews were conducted with 210 overweight or obese patients recruited from the clinics to determine patients' recall of physicians' weight loss recommendations, and patients' understanding of the relationship between weight and health, and their stages of readiness for weight loss.

RESULTS

Physicians identified major barriers to providing weight loss counseling, including insufficient confidence, knowledge, and skills. Obesity was underdocumented as a distinct clinical diagnosis. Only 5% of the patients recalled being given the combined weight loss strategy of diet and exercise. However, patients who recalled being counseled to lose weight were more likely to understand the risks of obesity, the benefits of weight loss, and were at a higher stage of readiness for weight loss.

CONCLUSIONS

Physicians' weight loss counseling had a significant effect on patients' understanding of and motivation for weight loss. However, physicians provided insufficient guidance on weight management strategies, possibly because of inadequate counseling skills and confidence.

Assessing the transtheoretical model of change constructs for physicians counseling smokers

Baseline data from a population-based sample of 259 primary care physicians were used to examine the interrelations of 3 central constructs of the Transtheoretical Model of Change (TTM; stages of change, self-efficacy, and decisional balance) in regard to smoking cessation counseling behavior. In this article we explore the potential use of the TTM for future interventions to help understand and guide physicians' behavior change toward increasing adoption of smoking cessation interventions with their patients. It was hypothesized that self-efficacy and the decisional balance of counseling would be significantly related to physicians' stages of change, which in turn would be related to self-reported physician counseling behavior. Principal components analyses were conducted to examine the self-efficacy and decisional balance constructs. Coefficient alphas were.90 for self-efficacy and.84 and.78 for the pros and cons scales, respectively. Consistent with the TTM, analyses of variance revealed that later stages of physicians' readiness to provide smoking cessation counseling were associated with higher self-efficacy scores. Earlier stages showed significantly higher cons and lower pros of smoking cessation counseling. Structural equation modeling procedures supported the hypothesized path analysis model in which 3 constructs related to stage of readiness, which in turn related to reported physicians' counseling behavior.

Biopsychosocial characteristics of overweight and obese primary care patients: do psychosocial and behavior factors mediate sociodemographic effects?

BACKGROUND

The increasing prevalence of obesity and obesity-related conditions in primary care settings challenges the health care system. Thus, we used available baseline data from an on-going clinical trial to examine the biopsychosocial characteristics of overweight and obese primary care patients. The primary research objective was to ascertain whether theoretically important psychosocial and behavioral variables mediate the empirical relationships between sociodemographic factors and body mass index (BMI).

METHODS

Overweight or obese primary care patients (n=665) enrolled in an on-going trial of a cognitive-behavioral obesity intervention provided baseline sociodemographic, psychosocial, nutritional, physical activity, and anthropometric data that were analyzed via multiple regression.

RESULTS

Lower educational attainment was associated with a higher BMI after controlling for decisional balance, social support, self-efficacy, energy intake, and energy expenditure (P<0.05). In contrast, ethnicity was not associated with BMI after controlling for the psychosocial and behavioral variables. Decisional balance and social support variables were associated with BMI and energy intake, but the directions of some of the associations were not consistent with a priori expectations.

CONCLUSIONS

Overall, we found some evidence of mediation by the psychosocial and behavioral variables of the relationship between ethnicity and BMI, but not for the relationship between education and BMI. In addition, some of the relationships between the psychosocial variables and BMI were opposite of our expectations.

Assessing dietary and exercise stage of change to optimize weight loss interventions

OBJECTIVE

According to the Transtheoretical Model (TM), tailoring interventions to patients' readiness to change can enhance patient progress and help patients use therapeutic resources more effectively. However, tailoring an intervention depends on accurate assessment of patients' stage of change (SOC). This study describes a multi-item algorithm of SOC (M-SOC) for weight loss-related behaviors that attempts to overcome some of the conceptual and methodological difficulties encountered in previously SOC assessments.

RESEARCH METHODS

Data were collected from participants randomly assigned to the treatment arm of a clinical trial comparing a TM-based, cognitive-behavioral intervention with enhanced usual care for weight loss.

RESULTS

The stair-step relationships hypothesized by the TM between assessed SOC and key behavioral measures were found for all algorithms (p < 0.05), indicating that the M-SOC algorithm performs as well as single item algorithms. However, 50% fewer patients were classified in action or maintenance for dietary fat intake and portion control (p < 0.05) by the multiple-item algorithms, providing staging more consistent with the clinical presentation of obese individuals. In addition, logistic regression analyses indicated that the single-item algorithms were not sufficient predictors of these behavioral domains.

DISCUSSION

To the extent that treatment is guided by assessed SOC, there is potential for a considerable variability in interventions with different approaches to staging. For weight-loss interventions that target portion control and decreased fat intake, the multi-item SOC algorithms seem to be better guides for matching treatments to SOC.

Congruence of readiness to change, self-efficacy, and decisional balance for physical activity and dietary fat reduction

PURPOSE

The current study examines the relations between decisional balance and self-efficacy variables on stage of change between the behaviors of avoiding dietary fat and increasing exercise.

DESIGN

A cross-sectional design was used.

SETTING

The current study took place in public primary care clinics from four sites across Louisiana. Clinics were associated with teaching hospitals and located in urban and rural areas.

SUBJECTS

Subjects included 515 adult outpatients, 60% African-American, 81% women, and 43% married. The age ranged from 18 to 87 years old, and the mean age was 45 (SD = 14). Patients were predominantly low-income (mean household income of $490 per month) and uninsured (71%).

MEASURES

Standard questionnaires were given to asses stage of change, decisional balance, and self-efficacy for exercise and dietary fat reduction.

RESULTS

Although the chi 2 analysis revealed that dietary fat and exercise stage of change were significantly related, Pearson chi 2 (df = 16) = 74.30, p < .001, 35% of the sample was stage incongruent between behaviors (e.g., a significant percentage of exercise maintainers were precontemplators for reducing dietary fat). Only 27% of the sample was in the same stage for both behaviors. Correlations and multivariate analyses of variance (MANOVAs) indicated that relationships between behaviors were similar to those found previously within behaviors; however, the effect sizes were markedly attenuated.

CONCLUSIONS

These results have implications for healthcare providers working with weight management. Accurate assessment of readiness for change for both exercise and dietary fat consumption is critical. For many patients, readiness for change differs dramatically between the two behaviors, and interventions may need to be tailored more precisely. Providers may need to use more active, behaviorally focused interventions for the more advanced behavior while simultaneously implementing more cognitively focused interventions for the less advanced one.

Physician involvement in the management of obesity as a primary medical condition

As the obesity epidemic escalates, increasing numbers of patients present with serious comorbidities related to excess body weight. Obesity should be recognized and treated as a primary medical condition that is progressive, chronic, and relapsing. Effective treatment of obesity has been shown to reduce cardiovascular risk factors and comorbid conditions. Physician involvement is necessary for medical assessment, management, counseling, and coordination of multidisciplinary obesity treatment. Obese patients who receive counseling and weight management from physicians are significantly more likely to undertake weight management programs than those who do not. Obesity treatment guidelines and materials are available from various health organizations. A comprehensive weight management program must include dietary adjustments, increased physical activity, and behavioral modification. Nutritional modifications should take into account the diet's energy content, composition, and suitability for the individual patient. The physical activity component should be safe and practical, including aerobic activity, strength training, and increased daily lifestyle activities. Various behavioral strategies enable the patient to make lifestyle changes that will promote weight loss and management. Adjunct therapies may serve to support lifestyle modifications in severe or resistant cases of obesity. Models for multidisciplinary care vary depending on whether they are designed for an individual medical practice or as part of the health care services of a larger facility. Lifestyle changes for healthy weight management must be permanently incorporated into a patient's daily lifestyle to reduce obesity and its associated health risks. Such intervention is necessary if the growing epidemic of obesity is to be slowed and reversed.

Implementation of a primary care physician network obesity management program

Most primary care physicians do not treat obesity, citing lack of time, resources, insurance reimbursement, and knowledge of effective interventions as significant barriers. To address this need, a 10-minute intervention delivered by the primary care physician was coupled with individual dietary counseling sessions delivered by a registered dietitian via telephone with an automated calling system (House-Calls, Mobile, AL). Patients were seen for follow-up by their physician at weeks 4, 12, 24, 36 and 52. A total of 252 patients (202 women and 50 men) were referred by 18 primary care physicians to the program. The comorbid conditions reported for all patients at baseline included low back pain, 29% (n = 72); hypertension, 45% (n = 113); hypercholesterolemia, 41% (n = 104); type 2 diabetes, 10% (n = 26); and sleep apnea, 5% (n = 12). When offered a choice of meal plans based on foods or meal replacements, two-thirds of patients (n = 166) chose to use meal replacements (Ultra Slim-Fast; Slim-Fast Foods Co., West Palm Beach, FL) at least once daily. Baseline weights of subjects averaged 200 +/- 46 lb for women (n = 202) and 237 +/- 45 lb for men (n = 50). Patients completing 6 months in the program lost an average of 19.0 +/- 4.0 lb for women (n = 94) and 15.5 +/- 8.2 lb for men (n = 26). Physicians reported a high degree of satisfaction with the program, suggesting that a brief, effective physician-directed program with nutritionist support by telephone can be implemented in a busy primary care office.