Obesity and Physician Advice to Achieve Weight Loss
By Tadd J. Maxfield, DO, MA Ed and Marian B. Maxfield, M Ed, PhD candidate
Abstract: Obesity in the United States is becoming increasingly prevalent. Obese persons make up more than one third of the population. The opportunity for physicians, especially primary care physicians, to address this issue is even more urgent as the adolescent population meets unprecedented levels of obesity. The authors conducted a survey among new patients in a primary care office. The survey contained questions about patient experiences with prior physicians over a two-year period. The data was analyzed using contingency tables, percentages, and bar graphs. Results of the survey determined that area physicians are deficient in the following: recognition of overweight and obese patients, advising appropriate patients to lose weight, and recommending effective methods to help patients achieve weight loss. The authors conclude with recommendations for primary care physicians to utilize when treating overweight and obese patients.
Obesity is increasing at an alarming rate. In fact, over one-third of the adult U.S. population is obese.1 Considering the number of children who are becoming obese, the adult obesity epidemic is likely to increase2. Due to the increased comorbidities that are attributed to obesity, such as hypertension, sleep apnea, type 2 diabetes, coronary heart disease, gallbladder disease, and osteoarthritis,3 the national burden of healthcare costs related to obesity is more than 61 billion dollars annually.4
Physicians are well informed regarding the importance of weight loss among patients. Although there is considerable research documenting overweight and obese people in the United States, there is limited research on the impact of physician advice versus no advice on prior weight loss of obese patients. The purpose of this study was to address the obesity epidemic by collecting data on body mass index (BMI), physician advice versus no advice, the frequency of physician advice, and physician-prescribed methods of weight loss. The study sought to determine answers to the following questions:
Methods
Surveys were directly administered to new patients seeking any treatment in a primary care office of an osteopathic teaching hospital located in northeastern Ohio during a period of one year, from 2005-2006. The target population was patients 18 years of age or older who live in a medically underserved area. Survey completion was voluntary and was distributed with other medical documentation commonly given to new patients for completion.
Patients were asked to indicate their height, and in order to calculate the patient’s BMI, the registering nurse for each participating patient documented the patient’s weight on the survey during the acquisition of routine vitals. No patient identifiers were recorded on the surveys. The office staff members who were directly involved with patient contact during the registration process were trained in the distribution, voluntary completion, and collection of the instruments before beginning the study. IRB permission was granted to perform the study.
The questionnaire involved a short explanation of the purpose of the survey, a concise statement of the voluntary nature of the survey, followed by 13 closed-ended questions involving the patient’s experience with any physician during the past 2 years regarding weight loss. Elements of the questionnaire were originally used in a telephone survey by the Centers for Disease Control Prevention and Health Promotion in 2002. An expert in the field examined the instrument in order to obtain content-related validity of the survey instrument.
The survey data was analyzed utilizing descriptive statistics. The quantitative data were evaluated using percentages, means, and standard deviations. The categorical data were examined using contingency tables, percentages, and bar graphs.
Results
A total of 107 surveys were collected, 53 (49.5 percent) from males, 54 (50.5 percent) from females. The mean age of the participants was 35.8 years old, with a range from 18 to 75 years old. The mean BMI of 102 valid surveys was 29.38 mg/kg2, ranging from a minimum of 17.9 to a maximum of 49.8 (Figure 1).
Patients were surveyed about their amount of weight loss either with physician advice or without physician advice. A total of 74 patients responded and 86.4 percent lost weight without advice and 23 percent with advice. A descriptive analysis of the amount of weight lost in each group indicates that a difference exists between the means of the no physician advice group (M = 28.05, SD = 28.85) and with physician advice group (M = 7.33, SD = 17.10).
Patients were surveyed concerning their encounters in the past two years with physicians in respect to advice on weight loss. Twenty-one percent were advised to lose weight, 1 percent were advised to gain weight and 78.1 percent admitted trying to lose weight without the advice of a physician. 30.8 percent attempted to lose weight 1-2 different times without physician advice, and 14 percent attempted 10 or more times without the advice of a physician. Remaining patients attempted weight loss between 3 to 9 times.
Of the 21 percent of patients advised to lose weight, 3.1 percent of patients were advised to lose weight at every visit, 2.1 percent at almost every visit, 3.1 percent at about every other visit, and 22.9 percent were advised to lose weight once in a while. The determination of physician utilization of BMI as a means of selecting which patients to advise was calculated by comparing the data of physician advice and BMI categories of patients. Table 1 indicates physician advice when applied to the following BMI categories: overweight, obesity class I, II, and III. BMI categories and ranges were based on the International Classification from the World Health Organization.5
A total of 23.3 percent of patients lost weight when they were given one or more recommended weight loss methods. The incidence of patients who received the various weight loss methods is provided in Table 2. The amount of weight lost from all of the recommended methods combined was zero pounds in 76.7 percent of patients, 10 pounds in 6.7 percent, 15 to 45 pounds in 10 percent, and 60 pounds in 6.7 percent of patients.
Patient Selection and Frequency of Advice
The data demonstrate that physicians are more likely to give advice in frequencies that are proportionate to the BMI (Table 1). Intuitively, one would expect physicians to be more motivated to address weight loss if patients present with more extreme obesity conditions. This outcome is promising, as even though physicians did not demonstrate strength in their frequency of advice, they did recognize the necessity for weight loss in patients who needed it most.
It is recommended that physicians advise patients about weight loss frequently and consistently, especially if the patient is obese. This study indicates the frequency of weight loss advice at every visit (3.1 percent) and every other visit (3.1 percent) was minimal. This could account for the minimal average weight loss of patients in the advice group. A question for further research is to investigate what effect physicians have who intervene every visit with weight loss advice and this effect on the amount of weight lost by obese patients over a period of time.
With vs. Without Advice
The results of this study demonstrate that of the two groups, the group that was not given physician advice was more successful in weight loss (M = 28.05, SD = 28.85) than the group that was given advice (M = 7.33, SD = 17.10). These results suggest that patients have more success at weight loss when a physician does not intervene. A potential explanation for this outcome is that even though physicians may know methods that yield weight loss, patients may make more attempts on their own due to the variety of methods available to the general public. Patients may commit to a method that appeals to them, thus allowing the patient to achieve greater success. Research has demonstrated that a combination of diet and exercise gleans lasting weight loss6, and methods that are considered ‘fun’ for patients will be adhered to for longer spans of time, resulting in more successful long-term weight loss and weight management.7 The maintenance of attained weight loss for the surveyed patients is unknown and should be researched further.
Recommended Methods
Numerous national organizations have published practice policy statements on weight management counseling for physicians. The guidelines are especially important for those in primary care fields due to the increased patient continuity that these branches of medicine afford. The data from this study suggests that physicians are recommending two effective methods (diet 15.2 percent and exercise 39.2 percent), suggested by the guidelines. Practice policy statements also recommend a combination of the two as a ‘best practice’.6,7,8 Only 24.2 percent of patients received a ‘best practices’ weight loss modality, which may partially explain the poor results of the physician-recommended weight loss group.
Limitations
Generalizability is limited due to the design of the survey and small sample size within the groups. The variables researched on the survey were ex post facto, which meant the variables were not manipulated by the researcher and cannot be generalized to a larger population. The sample size was small, resulting in an inability to calculate statistical significance with the use of inferential statistical analysis. The study should be replicated with an experimental research design and a larger sample size.
Generalizablity was limited due to small sample size, lack of manipulation of variables, and the voluntary nature of the study. Replication of the study at a greater number of sites and participants would increase the accuracy of results. Scheduled reminders to the office staff may have increased survey yields, as distribution of the surveys by the office staff was found to be inconsistent by the site supervisor. This study required patients to provide their height measurements on the survey. Potential variation could have occurred considering that patients will over-report their height, especially when patients are specifically seeking help for weight loss.11 The development of further studies allowing generalizability to a larger population is planned by the authors, using a quasi-experimental study comparing advice and non-advice according to body mass index.
Suggestions for Primary Care Physicians
Based on the data from the study, the authors recommend the following to assist patients in achieving weight loss when indicated:
Conclusion
Obesity is recognized as an ever-increasing threat to the general health of the United States population. This study shows that physicians are advising overweight and obese patients to lose weight, but in disappointing numbers. Osteopathic primary care physicians have an urgent, prime opportunity to address the concern of weight loss in overweight and obese patients. The need to address the whole patient, especially in this era of medicine, is especially important to slow the growth of the obesity epidemic. Using the tools and suggestions presented through this research study, physicians and their patients can be more successful in reaching this goal.
Dr. Maxfield is the chief resident of family medicine at Cuyahoga Falls General Hospital, Cuyahoga Falls, Ohio. Mrs. Maxfield is adjunct faculty and is completing her dissertation in the Department of Instructional Technology at Kent State University, Kent, Ohio.
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