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Can effective obesity counseling fit into the 20-minute appointment?

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Yes, by using a pre-visit questionnaire that zeroes in on weight history, eating habits, and level of physical activity. This information will lay the foundation for effective weight loss counseling and interventions consistent with intensive behavioral therapy for obesity, reimbursable by Medicare.1

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The 5 A's approach to reimbursable obesity counseling
Table 1 displays a targeted counseling approach integrating the 5-A framework (assess, advise, agree, assist, arrange), as described in the Medicare requirements for reimbursable intensive behavioral therapy.1,2 Based on our experience, this approach can be easily achieved in the 20-minute appointment when the relevant information is collected in advance of the visit.

More than one-third of US adults are obese.3 And even though the rate of obesity in adults has leveled off since 2009,3 more needs to be done to bend the arc of the national obesity trend. Clinicians tend to focus on the complications of obesity (coronary artery disease, type 2 diabetes, hypertension, hyperlipidemia) rather than on early identification and intervention of obesity itself.4–6 A national study of outpatient visits showed that only 29% of visits by patients who were obese according to their body mass index (BMI) had a documented diagnosis of obesity, suggesting a profound under­diagnosis of obesity.7 According to one study, primary care doctors lack the level of comfort and counseling experience needed to provide obesity and weight loss counseling.8 Yet recent changes to Medicare reimbursement encourage obesity screening and management by covering up to 20 visits for intensive behavioral therapy to treat obesity.1

We offer the following targeted approach to counseling, achievable within the context of a primary care visit and based on recent evidence, including the 2013 joint guidelines for the treatment of obesity of the American College of Cardiology, the American Heart Association Task Force on Practice Guidelines, and the Obesity Society.2


Measure the patient’s height and weight with the patient wearing light clothing and no shoes, and calculate the BMI as the weight in kilograms divided by the square of the height in meters. A BMI of 30 kg/m2 or greater defines obesity.


According to the 2013 joint guidelines,2 when obtaining a thorough obesity history, the physician should do the following:

  • Obtain information about weight the patient has gained and lost over time and previous weight loss efforts
  • Ask the patient about eating habits, including number of meals per day, and the contents of a typical breakfast, lunch, and dinner; we recommend also asking about the number of daily beverages high in sugar
  • Quantify the type and amount of physical activity performed within a specific time period.

This information can be obtained in advance of an office visit through either an electronic medical record portal or a pre-visit questionnaire (eg, http://onlinelibrary.wiley.com/doi/10.1038/oby.2002.205/full).

Also assess the patient’s risk of cardiovascular and obesity-related comorbidities. The waist circumference for patients with a BMI between 25 and 35 kg/m2 provides additional information on risk: eg, a waist circumference greater than 88 cm for women and greater than 102 cm for men indicates increased cardiometabolic risk.2


Use a shared decision-making process to arrive at a set of incremental goals centered around the following evidence-based targets2:

  • Weight loss: 3% to 5% of baseline weight within 6 months
  • 6-month commitment to a weight loss intervention
  • Exercise: at least 150 minutes of moderate aerobic activity per week
  • More vegetables, fewer carbohydrates, and less protein, according to the American Diabetes Association’s “Create your plate” plan9
  • Mediterranean diet.10

Use motivational interviewing techniques along with the obesity history to negotiate goals. Exercise-related goals should consider the patient’s cardiovascular and musculoskeletal comorbidities.

Next Article:

Obesity counseling: Beyond ‘eat less, move more’

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