Weight Management: What Patients Want from Their Primary Care Physicians

Obesity is a common condition with associated risks of morbidity and mortality.^1,2 Recent studies suggest that rates of obesity and overweight are increasing in the United States.^3,4 Primary care physicians are struggling to incorporate weight management issues into their daily practices and often do not find the time to discuss this issue with their patients.^5-14 In recent years, obesity experts have developed guidelines to help physicians assist their obese patients with losing weight.^15-18 As primary care physicians look for ways to implement these guidelines with positive results, an understanding of patients’ weight management experiences and expectations in the physician-patient setting will be helpful. Unfortunately, few studies have addressed this topic.^19-21 With this study, we hoped to gain greater understanding of weight management issues from the patient’s point of view.

Methods

Research Environment

Two primary care practices in San Francisco were used as the study settings; both are affiliated with the University of California, San Francisco (UCSF): (1) the UCSF Medical Group at Parnassus Heights (which included 5 family physicians and 2 general internists), and (2) the UCSF Medical Group at Lakeshore (which included 4 family physicians and 1 general internist). Approximately two thirds of the patients in these practices had managed care insurance; 10% had Medicare; and 10% had Medicaid. The remaining patients paid for health care with other forms of fee-for-service reimbursement.

Sample Selection

During June and July 1997, we approached 214 adult patients at Parnassus Heights and 196 patients at Lakeshore to ask them to participate in our study. These 410 participants were drawn from consecutive samples of patients who were in the waiting room for a primary care visit. Pregnant patients, those younger than 18 years, and those who could not read English were excluded from the survey. We enrolled 366 (89%) of the patients approached.

Research Instrument

The participants completed an anonymous survey containing 15 general questions that required either yes or no responses or a selection from a list of choices. Only patients reporting that they needed to lose weight were asked how their weight affects them, their weight loss goals, and the role of their primary care physicians in helping them achieve these goals. However, all patients were asked if they had discussed their weight with their physicians in the past and whether they would feel comfortable discussing it with them in the future. Also, all patients were asked to describe the interventions used by their physicians in the past and those they would like to receive in the future. Finally, all patients were asked to provide demographic information and comorbidities. They were then directed to remove their shoes and coats and had weight and height recorded on a calibrated scale.

Statistical Analyses

We used the patients’ measurements to calculate body mass index (BMI=weight in kg/height in m²). The patients were then divided into 3 groups: those who were not overweight (BMI <25), those who were overweight (BMI=25-30), and those who were obese (BMI >30). The chi-square statistic was used to determine statistically significant associations between these groups and their responses to survey questions. We used analysis of variance testing to compare means between groups. The McNemar test was used to determine whether there was a statistically significant difference between patients’ past experiences and future preferences for intervention by their primary care physician. Finally, we did stepwise logistic regression analyses to determine predictors of patients reporting any communication with their physicians about their weight, and to determine predictors of overweight and obese patients reporting previous help with weight loss from their physicians. Odds ratios and 95% confidence intervals were determined. We conducted all analyses using SAS software.²²

Results

Patient Characteristics

The demographic characteristics of the patients are presented in Table 1. We found that 160 patients (44%) were not overweight, 101 (28%) were overweight, and 106 (29%) were obese. The patients in each group were similar in the number of visits to and the length of time with their primary care physicians. Obese patients were more likely to be African American or Latino and were less likely to be Asian American than patients who were not obese (P <.001). The prevalence of obesity-related comorbidities increased with higher BMI (P <.001). Ninety-seven percent of obese patients, 84% of overweight patients, and 39% of non-overweight patients felt they needed to lose weight (P <.001).

Prevalence of Physician-Patient Communication About Weight

We asked all patients if they had discussed their weight with their physicians in the past Table 2. Patients with higher BMIs were more likely to have had such a discussion. Those with lower BMIs were more likely to indicate that they had not needed help from their physicians with their weight in the past, and they were also more likely to indicate that they did not want such help in the future (P <.001 for all associations). Nearly all patients said they would be comfortable discussing weight with their physicians.

Attitudes of Patients Who Think They Need to Lose Weight

Table 3 shows the attitudes of patients who said they needed to lose weight. Most patients in all 3 categories indicated that weight loss was important to them and that their weight affected their happiness. However, patients with a higher BMI were more likely to state that their weight affects their health. Most patients in each group chose exercise and diet as the best methods of weight loss. However, patients with higher BMIs were more likely to want to be referred to a weight loss program. These patients were also more likely both to have felt that their physicians had helped in the past and that they could help in the future, and these patients had more ambitious weight loss goals (P <.001 for all associations).

What Was Done in the Past and What Patients Want in the Future

We asked all patients (regardless of whether they said they needed to lose weight) what their physicians had done about their weight in the past and what they would like from their physicians in the future Table 4. The most common experience reported was that physicians had not brought up weight. The patients reported a variety of other interventions that occurred, but none with a frequency greater than 20%. However, obese patients reported that their physicians intervened more. Although 33% of obese patients reported that their physicians had not brought up their weight, 48% of those patients said that they had been told to lose weight. The most common additional interventions reported by obese patients were: (1) a discussion of the health risks of obesity (31%), (2) exercise recommendations (30%), and (3) dietary advice (27%).

The most commonly cited future preferences for physician assistance of all patients were: (1) dietary advice (28%), (2) help setting realistic weight goals (27%), and (3) exercise recommendations (26%). The least-desired specific interventions were for their physicians to not bring up weight (12%) and for the physicians to say they do not have a weight problems (3%). Patients in all groups wanted substantially more future involvement by their physicians than they had experienced in the past, especially in setting realistic weight goals. Patients with higher BMIs were more likely to report both a higher level of intervention in the past and a desire for a higher level of intervention in the future. For example, although 13% of the obese patients stated that their physicians had helped them set realistic weight goals in the past, 46% said they would like their physicians to help them set realistic weight goals in the future, a difference of 33% (P <.001).

Predictors of Physician-Patient Communication About Weight

We did stepwise logistic regression analyses to determine predictors of physician-patient communication about weight. The logistic regression models offered the variables of Table 1 and patient BMI as candidates for consideration of statistical significance. For patients with BMIs less than 25 (not overweight), we found no significant predictors of such communication. For patients with BMIs greater than 25 (overweight or obese), we found that the diagnoses of diabetes (odds ratio [OR] =3.2; 95% confidence interval [CI], 1.2-9.2), high cholesterol (OR=2.6; 95% CI, 1.1-6.0), and depression (OR=2.4; 95% CI, 1.0-5.7) were predictive of patients reporting such a discussion had occurred in the past. Also, higher BMIs were also predictive of physician-patient communication about weight (OR=1.2; 95% CI, 1.1-1.3).

Interventions Used by Physicians Who Helped Patients Lose Weight

Of the 206 patients in our study who were either obese or overweight (BMI >25), 37 (18%) said that their current physicians had helped them lose weight in the past. We did a stepwise logistic regression analysis to learn more about what physician behaviors were predictive of this outcome. The logistic regression models offered the variables in Table 1 and patient BMI as candidates for consideration of statistical significance, as well as the items listed in Table 4. Physicians given credit by obese or overweight patients for helping them to lose weight in the past were more likely to have referred patients to weight loss groups and programs (OR=9.9; 95% CI, 1.9-59.6), made exercise recommendations (OR=9.3; 95% CI, 2.7-35.7), and helped patients understand the risks of their weight to their health (OR=4.5; 95% CI, 1.3-15.4).

Discussion

Nearly all patients in this diverse primary care population who might benefit from weight loss believed that they should lose weight. Most indicated that diet and exercise were the best weight loss methods for them. Also, 35% of obese patients and 20% of overweight patients believed that referral to a weight loss program could help them lose weight. Obese and overweight patients were generally receptive to the involvement of their primary care physicians with their weight concerns.

Unfortunately, only a minority of obese and overweight patients said they had discussed weight with their physicians in the past. We found that physicians targeted their communication about weight to patients with higher BMIs and obesity-related comorbidities. Similar findings have been reported by others in recent years.^9,12,14 Although this selective approach may have merit, it may also ignore the larger population of obese and overweight patients who may be receptive to a physician’s help with these issues. Also, it raises the question of whether primary care physicians are neglecting their responsibility to address weight management with patients before comorbidities develop.

The most common weight loss approaches used by physicians for obese patients were: (1) telling their patients to lose weight (48%) and (2) not bringing up the subject of their weight (33%). By far the most common weight loss approach physicians used for overweight patients was not bringing up their weight (64%). Also, although some patients said they wanted to be told by their physicians to lose weight (39% of obese patients and 13% of overweight patients), many wanted a more comprehensive approach, including dietary advice, exercise recommendations, and help in setting realistic weight goals. These results suggest that even when primary care physicians address weight issues with obese and overweight patients the discussion is not as intensive as many patients would like.

The diversity of responses given by obese and overweight patients suggests that physicians will need to tailor their advice to the individual needs of patients. However, we found that the small number of obese and overweight patients who credited their physicians with helping them lose weight were more likely to have received a few specific interventions. In particular, these patients were significantly more likely to have been referred to weight loss groups or programs, to have received exercise recommendations, and to have been given insights into the risks of their weight to their health. These might be important features for primary care physicians to consider incorporating into their approach to weight loss with their obese and overweight patients.

Perhaps the most surprising finding is that 39% of patients with BMIs less than 25 thought they should lose weight. Although a relatively small number of these patients may benefit from weight loss because of an unusually high waist-to-hip ratio or certain comorbidities that could confer increased risk,¹⁷ it is unlikely that more than a few of them would benefit medically from weight loss. Thus, physicians may need to work individually with these non-overweight patients to dispel myths and help them feel happier with their current weight.

Primary care physicians generally agree that prevention, identification, and treatment of weight problems and its comorbidities should be within their scope of practice.^23,24 Lack of time, training, teaching materials, staff support, and adequate reimbursement have been cited as common reasons they fail to address these issues more often in clinical practice.²⁵ Also, some physicians may not bring up weight issues for fear of negative patient reactions—fears that may have merit in some cases.²⁶ However, our study shows that the vast majority of patients are willing and even eager to discuss weight with their current primary care physicians.

Physicians may also neglect to bring up weight-related issues because they are uncertain whether such a discussion will have a positive impact on the health of their patients. A recent study confirmed that many obese and overweight patients who are seen in primary care are not ready to make the lifestyle changes needed for sustained weight loss.²¹ However, other studies suggest that physician encouragement can increase a patient’s readiness to make important lifestyle changes over time.^27,28 Recent studies also suggest that a physician’s advice to exercise can significantly improve activity levels over a several-month period.²⁹

Limitations

Our study was limited by its relatively small sample of patients in 2 group practices in San Francisco. However, the demographic findings were similar to those in larger studies, showing increasing rates of obesity in African Americans and Latinos and increasing rates of comorbidities such as diabetes mellitus, high blood pressure, and hyperlipidemia among those who were more overweight.² Thus, there is reason to believe that our study population has similarities to larger randomly selected primary care populations used to study some of these issues in the past. Another limitation is that all the data except for BMI were obtained from self-report of patients. However, although patients might underreport the level of communication they have with their physicians, patient self-report may ultimately be the most relevant measure of what communication is remembered by the patient.

Conclusions

The results of our study demonstrate that most patients, regardless of their weight, are open to greater physician involvement in weight management. This is important information for primary care physicians who want to address these needs. More research is needed to develop effective primary care approaches to weight management that are flexible and sensitive enough to meet the diverse needs of all patients.

Acknowledgments

This research was partially supported by a grant (#5D32PE19036-09) from the Health Resources Services Administration of the US Department of Health and Human Services to aid in the establishment of a department of family practice and by a grant from the California Academy of Family Physicians. We would also like to acknowledge Laurel Mellin, RD, who assisted with the development of the research instrument; Kim P. Truong, DO, who assisted with data collection; and Robert Wilson, PhD, who assisted with statistical analysis.

Related Resources

• National Heart, Lung and Blood Institute: clinical guidelines for obesity http://www.nhlbi.nih.gov/guidelines/obesity/ob_home.htm Includes the NIH guidelines on weight management and access to numerous clinical tools for physicians and patients.
• Shape Up America! http://www.shapeup.org/ A joint effort of Shape Up America! and the American Obesity Association, with numerous links that are relevant to clinicians and patients.

Obesity is a common condition with associated risks of morbidity and mortality.^1,2 Recent studies suggest that rates of obesity and overweight are increasing in the United States.^3,4 Primary care physicians are struggling to incorporate weight management issues into their daily practices and often do not find the time to discuss this issue with their patients.^5-14 In recent years, obesity experts have developed guidelines to help physicians assist their obese patients with losing weight.^15-18 As primary care physicians look for ways to implement these guidelines with positive results, an understanding of patients’ weight management experiences and expectations in the physician-patient setting will be helpful. Unfortunately, few studies have addressed this topic.^19-21 With this study, we hoped to gain greater understanding of weight management issues from the patient’s point of view.

Methods

Research Environment

Two primary care practices in San Francisco were used as the study settings; both are affiliated with the University of California, San Francisco (UCSF): (1) the UCSF Medical Group at Parnassus Heights (which included 5 family physicians and 2 general internists), and (2) the UCSF Medical Group at Lakeshore (which included 4 family physicians and 1 general internist). Approximately two thirds of the patients in these practices had managed care insurance; 10% had Medicare; and 10% had Medicaid. The remaining patients paid for health care with other forms of fee-for-service reimbursement.

Sample Selection

During June and July 1997, we approached 214 adult patients at Parnassus Heights and 196 patients at Lakeshore to ask them to participate in our study. These 410 participants were drawn from consecutive samples of patients who were in the waiting room for a primary care visit. Pregnant patients, those younger than 18 years, and those who could not read English were excluded from the survey. We enrolled 366 (89%) of the patients approached.

Research Instrument

The participants completed an anonymous survey containing 15 general questions that required either yes or no responses or a selection from a list of choices. Only patients reporting that they needed to lose weight were asked how their weight affects them, their weight loss goals, and the role of their primary care physicians in helping them achieve these goals. However, all patients were asked if they had discussed their weight with their physicians in the past and whether they would feel comfortable discussing it with them in the future. Also, all patients were asked to describe the interventions used by their physicians in the past and those they would like to receive in the future. Finally, all patients were asked to provide demographic information and comorbidities. They were then directed to remove their shoes and coats and had weight and height recorded on a calibrated scale.

Statistical Analyses

We used the patients’ measurements to calculate body mass index (BMI=weight in kg/height in m²). The patients were then divided into 3 groups: those who were not overweight (BMI <25), those who were overweight (BMI=25-30), and those who were obese (BMI >30). The chi-square statistic was used to determine statistically significant associations between these groups and their responses to survey questions. We used analysis of variance testing to compare means between groups. The McNemar test was used to determine whether there was a statistically significant difference between patients’ past experiences and future preferences for intervention by their primary care physician. Finally, we did stepwise logistic regression analyses to determine predictors of patients reporting any communication with their physicians about their weight, and to determine predictors of overweight and obese patients reporting previous help with weight loss from their physicians. Odds ratios and 95% confidence intervals were determined. We conducted all analyses using SAS software.²²

Results

Patient Characteristics

The demographic characteristics of the patients are presented in Table 1. We found that 160 patients (44%) were not overweight, 101 (28%) were overweight, and 106 (29%) were obese. The patients in each group were similar in the number of visits to and the length of time with their primary care physicians. Obese patients were more likely to be African American or Latino and were less likely to be Asian American than patients who were not obese (P <.001). The prevalence of obesity-related comorbidities increased with higher BMI (P <.001). Ninety-seven percent of obese patients, 84% of overweight patients, and 39% of non-overweight patients felt they needed to lose weight (P <.001).

Prevalence of Physician-Patient Communication About Weight

We asked all patients if they had discussed their weight with their physicians in the past Table 2. Patients with higher BMIs were more likely to have had such a discussion. Those with lower BMIs were more likely to indicate that they had not needed help from their physicians with their weight in the past, and they were also more likely to indicate that they did not want such help in the future (P <.001 for all associations). Nearly all patients said they would be comfortable discussing weight with their physicians.

Attitudes of Patients Who Think They Need to Lose Weight

Table 3 shows the attitudes of patients who said they needed to lose weight. Most patients in all 3 categories indicated that weight loss was important to them and that their weight affected their happiness. However, patients with a higher BMI were more likely to state that their weight affects their health. Most patients in each group chose exercise and diet as the best methods of weight loss. However, patients with higher BMIs were more likely to want to be referred to a weight loss program. These patients were also more likely both to have felt that their physicians had helped in the past and that they could help in the future, and these patients had more ambitious weight loss goals (P <.001 for all associations).

What Was Done in the Past and What Patients Want in the Future

We asked all patients (regardless of whether they said they needed to lose weight) what their physicians had done about their weight in the past and what they would like from their physicians in the future Table 4. The most common experience reported was that physicians had not brought up weight. The patients reported a variety of other interventions that occurred, but none with a frequency greater than 20%. However, obese patients reported that their physicians intervened more. Although 33% of obese patients reported that their physicians had not brought up their weight, 48% of those patients said that they had been told to lose weight. The most common additional interventions reported by obese patients were: (1) a discussion of the health risks of obesity (31%), (2) exercise recommendations (30%), and (3) dietary advice (27%).

The most commonly cited future preferences for physician assistance of all patients were: (1) dietary advice (28%), (2) help setting realistic weight goals (27%), and (3) exercise recommendations (26%). The least-desired specific interventions were for their physicians to not bring up weight (12%) and for the physicians to say they do not have a weight problems (3%). Patients in all groups wanted substantially more future involvement by their physicians than they had experienced in the past, especially in setting realistic weight goals. Patients with higher BMIs were more likely to report both a higher level of intervention in the past and a desire for a higher level of intervention in the future. For example, although 13% of the obese patients stated that their physicians had helped them set realistic weight goals in the past, 46% said they would like their physicians to help them set realistic weight goals in the future, a difference of 33% (P <.001).

Predictors of Physician-Patient Communication About Weight

We did stepwise logistic regression analyses to determine predictors of physician-patient communication about weight. The logistic regression models offered the variables of Table 1 and patient BMI as candidates for consideration of statistical significance. For patients with BMIs less than 25 (not overweight), we found no significant predictors of such communication. For patients with BMIs greater than 25 (overweight or obese), we found that the diagnoses of diabetes (odds ratio [OR] =3.2; 95% confidence interval [CI], 1.2-9.2), high cholesterol (OR=2.6; 95% CI, 1.1-6.0), and depression (OR=2.4; 95% CI, 1.0-5.7) were predictive of patients reporting such a discussion had occurred in the past. Also, higher BMIs were also predictive of physician-patient communication about weight (OR=1.2; 95% CI, 1.1-1.3).

Interventions Used by Physicians Who Helped Patients Lose Weight

Of the 206 patients in our study who were either obese or overweight (BMI >25), 37 (18%) said that their current physicians had helped them lose weight in the past. We did a stepwise logistic regression analysis to learn more about what physician behaviors were predictive of this outcome. The logistic regression models offered the variables in Table 1 and patient BMI as candidates for consideration of statistical significance, as well as the items listed in Table 4. Physicians given credit by obese or overweight patients for helping them to lose weight in the past were more likely to have referred patients to weight loss groups and programs (OR=9.9; 95% CI, 1.9-59.6), made exercise recommendations (OR=9.3; 95% CI, 2.7-35.7), and helped patients understand the risks of their weight to their health (OR=4.5; 95% CI, 1.3-15.4).

Discussion

Nearly all patients in this diverse primary care population who might benefit from weight loss believed that they should lose weight. Most indicated that diet and exercise were the best weight loss methods for them. Also, 35% of obese patients and 20% of overweight patients believed that referral to a weight loss program could help them lose weight. Obese and overweight patients were generally receptive to the involvement of their primary care physicians with their weight concerns.

Unfortunately, only a minority of obese and overweight patients said they had discussed weight with their physicians in the past. We found that physicians targeted their communication about weight to patients with higher BMIs and obesity-related comorbidities. Similar findings have been reported by others in recent years.^9,12,14 Although this selective approach may have merit, it may also ignore the larger population of obese and overweight patients who may be receptive to a physician’s help with these issues. Also, it raises the question of whether primary care physicians are neglecting their responsibility to address weight management with patients before comorbidities develop.

The most common weight loss approaches used by physicians for obese patients were: (1) telling their patients to lose weight (48%) and (2) not bringing up the subject of their weight (33%). By far the most common weight loss approach physicians used for overweight patients was not bringing up their weight (64%). Also, although some patients said they wanted to be told by their physicians to lose weight (39% of obese patients and 13% of overweight patients), many wanted a more comprehensive approach, including dietary advice, exercise recommendations, and help in setting realistic weight goals. These results suggest that even when primary care physicians address weight issues with obese and overweight patients the discussion is not as intensive as many patients would like.

The diversity of responses given by obese and overweight patients suggests that physicians will need to tailor their advice to the individual needs of patients. However, we found that the small number of obese and overweight patients who credited their physicians with helping them lose weight were more likely to have received a few specific interventions. In particular, these patients were significantly more likely to have been referred to weight loss groups or programs, to have received exercise recommendations, and to have been given insights into the risks of their weight to their health. These might be important features for primary care physicians to consider incorporating into their approach to weight loss with their obese and overweight patients.

Perhaps the most surprising finding is that 39% of patients with BMIs less than 25 thought they should lose weight. Although a relatively small number of these patients may benefit from weight loss because of an unusually high waist-to-hip ratio or certain comorbidities that could confer increased risk,¹⁷ it is unlikely that more than a few of them would benefit medically from weight loss. Thus, physicians may need to work individually with these non-overweight patients to dispel myths and help them feel happier with their current weight.

Primary care physicians generally agree that prevention, identification, and treatment of weight problems and its comorbidities should be within their scope of practice.^23,24 Lack of time, training, teaching materials, staff support, and adequate reimbursement have been cited as common reasons they fail to address these issues more often in clinical practice.²⁵ Also, some physicians may not bring up weight issues for fear of negative patient reactions—fears that may have merit in some cases.²⁶ However, our study shows that the vast majority of patients are willing and even eager to discuss weight with their current primary care physicians.

Physicians may also neglect to bring up weight-related issues because they are uncertain whether such a discussion will have a positive impact on the health of their patients. A recent study confirmed that many obese and overweight patients who are seen in primary care are not ready to make the lifestyle changes needed for sustained weight loss.²¹ However, other studies suggest that physician encouragement can increase a patient’s readiness to make important lifestyle changes over time.^27,28 Recent studies also suggest that a physician’s advice to exercise can significantly improve activity levels over a several-month period.²⁹

Limitations

Our study was limited by its relatively small sample of patients in 2 group practices in San Francisco. However, the demographic findings were similar to those in larger studies, showing increasing rates of obesity in African Americans and Latinos and increasing rates of comorbidities such as diabetes mellitus, high blood pressure, and hyperlipidemia among those who were more overweight.² Thus, there is reason to believe that our study population has similarities to larger randomly selected primary care populations used to study some of these issues in the past. Another limitation is that all the data except for BMI were obtained from self-report of patients. However, although patients might underreport the level of communication they have with their physicians, patient self-report may ultimately be the most relevant measure of what communication is remembered by the patient.

Conclusions

The results of our study demonstrate that most patients, regardless of their weight, are open to greater physician involvement in weight management. This is important information for primary care physicians who want to address these needs. More research is needed to develop effective primary care approaches to weight management that are flexible and sensitive enough to meet the diverse needs of all patients.

Acknowledgments

This research was partially supported by a grant (#5D32PE19036-09) from the Health Resources Services Administration of the US Department of Health and Human Services to aid in the establishment of a department of family practice and by a grant from the California Academy of Family Physicians. We would also like to acknowledge Laurel Mellin, RD, who assisted with the development of the research instrument; Kim P. Truong, DO, who assisted with data collection; and Robert Wilson, PhD, who assisted with statistical analysis.

Related Resources

• National Heart, Lung and Blood Institute: clinical guidelines for obesity http://www.nhlbi.nih.gov/guidelines/obesity/ob_home.htm Includes the NIH guidelines on weight management and access to numerous clinical tools for physicians and patients.
• Shape Up America! http://www.shapeup.org/ A joint effort of Shape Up America! and the American Obesity Association, with numerous links that are relevant to clinicians and patients.

Obesity is a common condition with associated risks of morbidity and mortality.^1,2 Recent studies suggest that rates of obesity and overweight are increasing in the United States.^3,4 Primary care physicians are struggling to incorporate weight management issues into their daily practices and often do not find the time to discuss this issue with their patients.^5-14 In recent years, obesity experts have developed guidelines to help physicians assist their obese patients with losing weight.^15-18 As primary care physicians look for ways to implement these guidelines with positive results, an understanding of patients’ weight management experiences and expectations in the physician-patient setting will be helpful. Unfortunately, few studies have addressed this topic.^19-21 With this study, we hoped to gain greater understanding of weight management issues from the patient’s point of view.

Methods

Research Environment

Two primary care practices in San Francisco were used as the study settings; both are affiliated with the University of California, San Francisco (UCSF): (1) the UCSF Medical Group at Parnassus Heights (which included 5 family physicians and 2 general internists), and (2) the UCSF Medical Group at Lakeshore (which included 4 family physicians and 1 general internist). Approximately two thirds of the patients in these practices had managed care insurance; 10% had Medicare; and 10% had Medicaid. The remaining patients paid for health care with other forms of fee-for-service reimbursement.

Sample Selection

During June and July 1997, we approached 214 adult patients at Parnassus Heights and 196 patients at Lakeshore to ask them to participate in our study. These 410 participants were drawn from consecutive samples of patients who were in the waiting room for a primary care visit. Pregnant patients, those younger than 18 years, and those who could not read English were excluded from the survey. We enrolled 366 (89%) of the patients approached.

Research Instrument

The participants completed an anonymous survey containing 15 general questions that required either yes or no responses or a selection from a list of choices. Only patients reporting that they needed to lose weight were asked how their weight affects them, their weight loss goals, and the role of their primary care physicians in helping them achieve these goals. However, all patients were asked if they had discussed their weight with their physicians in the past and whether they would feel comfortable discussing it with them in the future. Also, all patients were asked to describe the interventions used by their physicians in the past and those they would like to receive in the future. Finally, all patients were asked to provide demographic information and comorbidities. They were then directed to remove their shoes and coats and had weight and height recorded on a calibrated scale.

Statistical Analyses

We used the patients’ measurements to calculate body mass index (BMI=weight in kg/height in m²). The patients were then divided into 3 groups: those who were not overweight (BMI <25), those who were overweight (BMI=25-30), and those who were obese (BMI >30). The chi-square statistic was used to determine statistically significant associations between these groups and their responses to survey questions. We used analysis of variance testing to compare means between groups. The McNemar test was used to determine whether there was a statistically significant difference between patients’ past experiences and future preferences for intervention by their primary care physician. Finally, we did stepwise logistic regression analyses to determine predictors of patients reporting any communication with their physicians about their weight, and to determine predictors of overweight and obese patients reporting previous help with weight loss from their physicians. Odds ratios and 95% confidence intervals were determined. We conducted all analyses using SAS software.²²

Results

Patient Characteristics

The demographic characteristics of the patients are presented in Table 1. We found that 160 patients (44%) were not overweight, 101 (28%) were overweight, and 106 (29%) were obese. The patients in each group were similar in the number of visits to and the length of time with their primary care physicians. Obese patients were more likely to be African American or Latino and were less likely to be Asian American than patients who were not obese (P <.001). The prevalence of obesity-related comorbidities increased with higher BMI (P <.001). Ninety-seven percent of obese patients, 84% of overweight patients, and 39% of non-overweight patients felt they needed to lose weight (P <.001).

Prevalence of Physician-Patient Communication About Weight

We asked all patients if they had discussed their weight with their physicians in the past Table 2. Patients with higher BMIs were more likely to have had such a discussion. Those with lower BMIs were more likely to indicate that they had not needed help from their physicians with their weight in the past, and they were also more likely to indicate that they did not want such help in the future (P <.001 for all associations). Nearly all patients said they would be comfortable discussing weight with their physicians.

Attitudes of Patients Who Think They Need to Lose Weight

Table 3 shows the attitudes of patients who said they needed to lose weight. Most patients in all 3 categories indicated that weight loss was important to them and that their weight affected their happiness. However, patients with a higher BMI were more likely to state that their weight affects their health. Most patients in each group chose exercise and diet as the best methods of weight loss. However, patients with higher BMIs were more likely to want to be referred to a weight loss program. These patients were also more likely both to have felt that their physicians had helped in the past and that they could help in the future, and these patients had more ambitious weight loss goals (P <.001 for all associations).

What Was Done in the Past and What Patients Want in the Future

We asked all patients (regardless of whether they said they needed to lose weight) what their physicians had done about their weight in the past and what they would like from their physicians in the future Table 4. The most common experience reported was that physicians had not brought up weight. The patients reported a variety of other interventions that occurred, but none with a frequency greater than 20%. However, obese patients reported that their physicians intervened more. Although 33% of obese patients reported that their physicians had not brought up their weight, 48% of those patients said that they had been told to lose weight. The most common additional interventions reported by obese patients were: (1) a discussion of the health risks of obesity (31%), (2) exercise recommendations (30%), and (3) dietary advice (27%).

The most commonly cited future preferences for physician assistance of all patients were: (1) dietary advice (28%), (2) help setting realistic weight goals (27%), and (3) exercise recommendations (26%). The least-desired specific interventions were for their physicians to not bring up weight (12%) and for the physicians to say they do not have a weight problems (3%). Patients in all groups wanted substantially more future involvement by their physicians than they had experienced in the past, especially in setting realistic weight goals. Patients with higher BMIs were more likely to report both a higher level of intervention in the past and a desire for a higher level of intervention in the future. For example, although 13% of the obese patients stated that their physicians had helped them set realistic weight goals in the past, 46% said they would like their physicians to help them set realistic weight goals in the future, a difference of 33% (P <.001).

Predictors of Physician-Patient Communication About Weight

We did stepwise logistic regression analyses to determine predictors of physician-patient communication about weight. The logistic regression models offered the variables of Table 1 and patient BMI as candidates for consideration of statistical significance. For patients with BMIs less than 25 (not overweight), we found no significant predictors of such communication. For patients with BMIs greater than 25 (overweight or obese), we found that the diagnoses of diabetes (odds ratio [OR] =3.2; 95% confidence interval [CI], 1.2-9.2), high cholesterol (OR=2.6; 95% CI, 1.1-6.0), and depression (OR=2.4; 95% CI, 1.0-5.7) were predictive of patients reporting such a discussion had occurred in the past. Also, higher BMIs were also predictive of physician-patient communication about weight (OR=1.2; 95% CI, 1.1-1.3).

Interventions Used by Physicians Who Helped Patients Lose Weight

Of the 206 patients in our study who were either obese or overweight (BMI >25), 37 (18%) said that their current physicians had helped them lose weight in the past. We did a stepwise logistic regression analysis to learn more about what physician behaviors were predictive of this outcome. The logistic regression models offered the variables in Table 1 and patient BMI as candidates for consideration of statistical significance, as well as the items listed in Table 4. Physicians given credit by obese or overweight patients for helping them to lose weight in the past were more likely to have referred patients to weight loss groups and programs (OR=9.9; 95% CI, 1.9-59.6), made exercise recommendations (OR=9.3; 95% CI, 2.7-35.7), and helped patients understand the risks of their weight to their health (OR=4.5; 95% CI, 1.3-15.4).

Discussion

Nearly all patients in this diverse primary care population who might benefit from weight loss believed that they should lose weight. Most indicated that diet and exercise were the best weight loss methods for them. Also, 35% of obese patients and 20% of overweight patients believed that referral to a weight loss program could help them lose weight. Obese and overweight patients were generally receptive to the involvement of their primary care physicians with their weight concerns.

Unfortunately, only a minority of obese and overweight patients said they had discussed weight with their physicians in the past. We found that physicians targeted their communication about weight to patients with higher BMIs and obesity-related comorbidities. Similar findings have been reported by others in recent years.^9,12,14 Although this selective approach may have merit, it may also ignore the larger population of obese and overweight patients who may be receptive to a physician’s help with these issues. Also, it raises the question of whether primary care physicians are neglecting their responsibility to address weight management with patients before comorbidities develop.

The most common weight loss approaches used by physicians for obese patients were: (1) telling their patients to lose weight (48%) and (2) not bringing up the subject of their weight (33%). By far the most common weight loss approach physicians used for overweight patients was not bringing up their weight (64%). Also, although some patients said they wanted to be told by their physicians to lose weight (39% of obese patients and 13% of overweight patients), many wanted a more comprehensive approach, including dietary advice, exercise recommendations, and help in setting realistic weight goals. These results suggest that even when primary care physicians address weight issues with obese and overweight patients the discussion is not as intensive as many patients would like.

The diversity of responses given by obese and overweight patients suggests that physicians will need to tailor their advice to the individual needs of patients. However, we found that the small number of obese and overweight patients who credited their physicians with helping them lose weight were more likely to have received a few specific interventions. In particular, these patients were significantly more likely to have been referred to weight loss groups or programs, to have received exercise recommendations, and to have been given insights into the risks of their weight to their health. These might be important features for primary care physicians to consider incorporating into their approach to weight loss with their obese and overweight patients.

Perhaps the most surprising finding is that 39% of patients with BMIs less than 25 thought they should lose weight. Although a relatively small number of these patients may benefit from weight loss because of an unusually high waist-to-hip ratio or certain comorbidities that could confer increased risk,¹⁷ it is unlikely that more than a few of them would benefit medically from weight loss. Thus, physicians may need to work individually with these non-overweight patients to dispel myths and help them feel happier with their current weight.

Primary care physicians generally agree that prevention, identification, and treatment of weight problems and its comorbidities should be within their scope of practice.^23,24 Lack of time, training, teaching materials, staff support, and adequate reimbursement have been cited as common reasons they fail to address these issues more often in clinical practice.²⁵ Also, some physicians may not bring up weight issues for fear of negative patient reactions—fears that may have merit in some cases.²⁶ However, our study shows that the vast majority of patients are willing and even eager to discuss weight with their current primary care physicians.

Physicians may also neglect to bring up weight-related issues because they are uncertain whether such a discussion will have a positive impact on the health of their patients. A recent study confirmed that many obese and overweight patients who are seen in primary care are not ready to make the lifestyle changes needed for sustained weight loss.²¹ However, other studies suggest that physician encouragement can increase a patient’s readiness to make important lifestyle changes over time.^27,28 Recent studies also suggest that a physician’s advice to exercise can significantly improve activity levels over a several-month period.²⁹

Limitations

Our study was limited by its relatively small sample of patients in 2 group practices in San Francisco. However, the demographic findings were similar to those in larger studies, showing increasing rates of obesity in African Americans and Latinos and increasing rates of comorbidities such as diabetes mellitus, high blood pressure, and hyperlipidemia among those who were more overweight.² Thus, there is reason to believe that our study population has similarities to larger randomly selected primary care populations used to study some of these issues in the past. Another limitation is that all the data except for BMI were obtained from self-report of patients. However, although patients might underreport the level of communication they have with their physicians, patient self-report may ultimately be the most relevant measure of what communication is remembered by the patient.

Conclusions

The results of our study demonstrate that most patients, regardless of their weight, are open to greater physician involvement in weight management. This is important information for primary care physicians who want to address these needs. More research is needed to develop effective primary care approaches to weight management that are flexible and sensitive enough to meet the diverse needs of all patients.

Acknowledgments

This research was partially supported by a grant (#5D32PE19036-09) from the Health Resources Services Administration of the US Department of Health and Human Services to aid in the establishment of a department of family practice and by a grant from the California Academy of Family Physicians. We would also like to acknowledge Laurel Mellin, RD, who assisted with the development of the research instrument; Kim P. Truong, DO, who assisted with data collection; and Robert Wilson, PhD, who assisted with statistical analysis.

Related Resources

• National Heart, Lung and Blood Institute: clinical guidelines for obesity http://www.nhlbi.nih.gov/guidelines/obesity/ob_home.htm Includes the NIH guidelines on weight management and access to numerous clinical tools for physicians and patients.
• Shape Up America! http://www.shapeup.org/ A joint effort of Shape Up America! and the American Obesity Association, with numerous links that are relevant to clinicians and patients.