Views of Primary Care Physicians Regarding the Promotion of Healthy Lifestyles and Weight Management Among Their Patients

From the University of Florida (Dr. Tucker, Ms. Ukonu, Ms. Kang, Ms. Good), Gainesville, FL; the University of Florida–Jacksonville (Dr. Shah, Dr. Bilello), Jacksonville, FL; and Ball State University (Dr. Arthur), Muncie, IN.

Abstracts

• Objective: To assess primary care physicians’ practices, knowledge, and beliefs regarding their efforts to promote healthy lifestyles and weight management among their patients.
• Methods: Study participants consisted of 25 primary care physicians from a regional primary care practice-based research network that includes 37 university-affiliated patient-centered medical homes and 2 nearby unaffiliated primary care sites. Participating physicians completed an online modified version of the Physician Survey of Practices on Diet, Physical Activity, and Weight Control–Adult Questionnaire.
• Results: The majority (88%) of participating physicians strongly believed it was their responsibility to promote a healthy diet, physical activity, and healthy weight loss and weight maintenance among patients. The 3 most commonly endorsed barriers were (a) not enough time, (b) minimal patient interest in improving his/her weight, and (c) lack of adequate weight-loss referral resources. The top 3 physician-perceived practice improvements that would be helpful with these practices were (a) better tools to communicate diet, physical activity, or weight problems to patients or family; (b) better mechanisms to connect patients to weight-loss referral resources; and (c) better counseling tools to guide patients regarding lifestyle modifications. 76% of the participating physicians correctly identified the BMI cutoff ranges for adult obesity, but only 32% did so for childhood obesity.
• Conclusion: It is important to provide primary care physicians with knowledge, effective tools, and resources to promote healthy lifestyles and weight loss and weight management among their patients.

Key words: obesity; primary care physicians; weight loss; weight management.

More than two-thirds of adults in the United States are overweight, with approximately 35% considered obese (defined as a body mass index ≥ 30) [1]. Obesity is associated with many of the leading causes of death in the United States (ie, diabetes, heart disease, stroke, and some types of cancer) and with poor mental health outcomes and reduced quality of life [2]. Racial/ethnic minorities and individuals with low incomes are disproportionately impacted by obesity and obesity-related diseases and negative health outcomes [3–5].

The US Preventive Services Task Force (USPSTF) recommends screening for obesity and intensive behavioral counseling, which are often the responsibilities of primary care providers [6]. Despite these recommendations, research suggests that primary care providers rarely screen their patients for obesity or refer them for intensive behavioral counseling despite evidence that doing so would improve patient health outcomes [5–7]. Lack of time to address weight issues during clinical visits, lack of training in weight management counseling, and lack of availability of intensive weight loss programs to which they can refer their patients are some of the reasons cited for not counseling patients about weight management [8].

Primary care providers deliver more hours of patient care than other providers, yet these providers have been unable to deliver medical interventions capable of producing even modest weight loss [10]. Obesity treatment options delivered in primary care settings have limited success, likely due to the low intensity of these treatment options. Many studies have shown that most obesity treatments in health care settings typically consist of scheduled monthly or quarterly visits that are 10 to 15 minutes in duration [11], despite evidence that more intense treatments are needed. Specifically, a systematic review of the obesity treatment literature performed by the USPSTF revealed that high-intensity, multicomponent behavioral interventions that include face-to-face counseling on diet and physical activity and behavioral therapy more than once a month for 3 months are needed to produce significant weight loss (8–15 lb) among adult patients in primary care settings [12].

Since many of the characteristics of multicomponent behavioral interventions for treating obesity are both patient-centered and involve self-management, the patient-centered medical home (PCMH) seems to be the ideal setting to deliver these interventions [13]. Specifically, PCMHs provide patient-centered care that is wide-ranging, team-based, and coordinated across all elements of the health care system and the patient’s community [14]. These sites specifically provide primary care, which is the type of care that obesity disparity patient groups such as racial/ethnic minorities, sexual minorities, groups with low incomes, and the medically underserved are more likely to utilize [15].

Providing multicomponent behavioral interventions for obesity in PCMHs and other primary care sites will increase the likelihood of participation among the aforementioned obesity disparity groups. Despite the potential benefits of obesity treatment interventions offered in primary care settings, particularly for obesity disparity groups, the role of primary care providers in providing such treatment interventions is not clear [16]. We surveyed primary care physicians who primarily worked in PCMHs to assess their practices, knowledge, views/beliefs, perceived barriers, and perceived needed clinic practice improvements relative to promoting healthy lifestyles and weight management among their patients.

Methods

Participants

Primary care physicians were recruited from among a regional primary care practice-based research network that includes 37 PCMHs affiliated with an academic health center and 2 nearby primary care sites not affiliated with an academic health center. Fifty-two physicians at these centers received an invitation via email to participate in our online survey study. The invitation email included (a) a study endorsement note from the chair of the Community Health and Family Medicine Department affiliated with the PCMHs, (b) instructions about how to participate in the study, and (c) a link to the study. Participation inclusion criteria specified in the online informed consent form were: (a) working as a physician affiliated with the practice-based research network, (b) having access to a computer with internet connection, (c) being able to communicate in written English, and (d) providing written consent to participate in the study. Physicians were not provided compensation for participating in the study.

Survey Instrument

To assess physicians’ views and practices, we used a modified version of the Physician Survey of Practices on Diet, Physical Activity, and Weight Control–Adult Questionnaire [17]. The survey was sponsored by the National Cancer Institute in collaboration with several other NIH institutes and the CDC for evaluating current clinical practices among physicians, including the degree to which physicians evaluate their patients for obesity and offer them guidance designed to increase adherence to a health-promoting lifestyle (eg, recommendations on diet, weight, and physical activity). Additionally, the questionnaire assesses physicians’ perceived barriers to patient assessment, evaluation, and management. It also includes questions about physicians’ healthy lifestyle–related knowledge. In 2010, Smith and colleagues utilized the questionnaire with a nationally representative sample of primary care physicians (n = 1211) to investigate primary care physicians’ clinical practices in relation to overweight and obesity [18]. To our knowledge, no other physician survey has been developed to assess current engagement in recommended clinical practices, barriers to engaging in recommended practices, as well as beliefs and knowledge regarding helping patients follow a health-promoting lifestyle. The original survey also includes questions regarding the physicians’ personal health status and health behaviors.

For our study, we modified the survey by removing questions regarding the physicians’ (a) perceived general health and well-being, (b) current dietary practices, (c) current level of engagement in physical activity, and (d) current engagement in professional activities unrelated to patient care (eg, research, teaching). Our modified survey included 7 questions asking about current practices regarding screening for obesity and referral of patients to weight management interventions. Two questions asked about physicians’ perceived barriers to helping patients adhere to a health-promoting lifestyle and maintain a healthy weight. Physicians were asked to rate their top 3 barriers from among a list of 11 pre-identified barriers and to rate their top 3 desired practice-related improvements from among a list of 10 pre-identified improvements. Physicians were given the option to provide additional barriers or improvements that were not already pre-identified. Seven questions assessed physicians’ views/beliefs related to helping patients achieve and maintain a health-promoting lifestyle and a healthy weight. These questions utilize a rating scale where 1 = strongly agree, 2 = agree somewhat, 3 = neither agree nor disagree, 4 = disagree somewhat, and 5 = strongly disagree. Four questions assessed physicians’ healthy lifestyle–related knowledge (BMI ranges/percentiles for adults/children, diet and exercise guideline recommendations [recommended amounts of moderate physical activity and servings of fruits and vegetables for adults]) and 11 questions ask about the physician (height, weight, demographics, and practice population).