Weight-loss talks: What works (and what doesn’t)

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Original Research

Weight-loss talks: What works (and what doesn’t)

J Fam Pract. 2011 April;60(4):213-219

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References

1. US Preventive Services Task Force. Screening for obesity in adults: recommendations and rationale. Ann Intern Med. 2003;139:930-932.

2. Nawaz H, Adams ML, Katz DL. Physician-patient interactions regarding diet, exercise, and smoking. Prev Med. 2000;31:652-657.

3. Sciamanna CN, Tate DF, Lang W, et al. Who reports receiving advice to lose weight? Results from a multistate survey. Arch Intern Med. 2000;160:2334-2339.

4. Galuska DA, Will JC, Serdula MK, et al. Are health care professionals advising obese patients to lose weight? JAMA. 1999;282:1576-1578.

5. Evans E. Why should obesity be managed? The obese individual’s perspective. Int J Obes Relat Metab Disord. 1999;23(suppl 4):S3-S6.

6. Mehrotra C, Naimi TS, Serdula M, et al. Arthritis, body mass index, and professional advice to lose weight: implications for clinical medicine and public health. Am J Prev Med. 2004;27:16-21.

7. Loureiro ML, Nayga RM Jr. Obesity, weight loss, and physician’s advice. Soc Sci Med. 2006;62:2458-2468.

8. Flocke SA, Clark A, Schlessman K, et al. Exercise, diet, and weight loss advice in the family medicine outpatient setting. Fam Med. 2005;37:415-421.

9. Alexander SC, Cox ME, Østbye T, et al. Do the 5 A’s work for weight-loss counseling? Presented at: International Conference on Communication in Healthcare; October 4–7, 2009; Miami, Fla.

10. McGinn T, Wyer PC, Newman TB, et al. Tips for learners of evidence-based medicine: 3. Measures of observer variability (kappa statistic). CMAJ. 2004;171:1369-1373.

11. Shannon J, Kristal AR, Curry SJ, et al. Application of a behavioral approach to measuring dietary change: the fat- and fiber-related diet behavior questionnaire. Cancer Epidemiol Biomarkers Prev. 1997;6:355-361.

12. Kristal AR, Shattuck AL, Henry HJ. Patterns of dietary behavior associated with selecting diets low in fat: reliability and validity of a behavioral approach to dietary assessment. J Am Diet Assoc. 1990;90:214-220.

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16. National Institutes of Health. The practical guide: identification, evaluation, and treatment of overweight and obesity in adults. NIH publication 00-4084. 2000. Available at: http://www.nhlbi.nih.gov/guidelines/obesity/prctgd_c.pdf. Accessed August 17, 2009.

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19. Miller WR, Rollnick SP, Miller WR. Motivational Interviewing: Preparing People for Change. 2nd ed. New York, NY: Guilford Press; 2002.

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Effect of type of advice on fat and fiber diet behavior score
Receipt of nutrition advice only was not associated with reduction in fat intake (P=.43, TABLE 2). However, those who received combined types of advice exhibited a significantly greater reduction of fat intake compared with those who received no advice (Fat- and Fiber-Related Diet Behavior Questionnaire score reduction of 0.15 vs 0.05; P=.02).

TABLE 2
How types of physician advice affected dietary fat intake, physical activity, and weight

	Type of advice
	None	Nutrition only	Physical activity only	Weight loss only	Combined advice	Nonspecific
Dietary fat change in Fat- and Fiber-Related Diet Behavior Questionnaire score differences
At 3 months from baseline (95% CI)	-0.05 (-0.11 to 0.004)	-0.10 (-0.22 to 0.01)	-0.07 (-0.16 to 0.02)	-0.08 (-0.26 to 0.09)	-0.15 (-0.20 to -0.09)	0.03 (0.11 to 0.18)
P value*		.43	.75	.73	.02	.31
Physical activity score (change in MET hours)
At 3 months from baseline (95% CI)	0.48 (-0.17 to 1.11)	0.83 (-0.51 to 2.14)	0.69 (-0.33 to 1.69)	-0.72 (-2.66 to 1.21)	0.24 (-0.40 to 0.86)	-0.07 (-1.74 to 1.59)
P value*		.64	.73	.25	.60	.55
Weight change (kg)
At 3 months from baseline (95% CI)	-0.18 (-0.39 to 0.75)	-0.18 (-1.38 to 1.02)	1.41 (0.51 to 2.31)	-0.26 (-1.99 to 1.47)	-0.55 (-1.12 to 0.02)	-0.62 (-2.11 to 0.87)
P value*		.59	.02	.63	.08	.32
CI, confidence interval; MET, metabolic equivalent tasks. *Test of difference between advice given and no advice given.

Effect of type of advice on Framingham Physical Activity score
No type of advice, including physical activity advice, led to a change in Framingham Physical Activity scores at the 3-month visit (overall P=.76; TABLE 2).

FAST TRACK

Nutrition advice alone was not associated with a reduction in fat intake.

Effect of type of advice on weight loss
Patients who received physical activity advice gained significantly more weight than patients who received no advice (1.41 kg gained vs 0.18 kg lost; P=.02). Patients who received combined advice lost more weight than patients who received no advice, but the difference did not reach statistical significance (0.55 kg lost vs 0.18 kg lost; P=.08).

Discussion

Physicians typically took an “all or nothing” approach to weight-related issues, giving no advice (37%) or a combination of nutrition, physical activity, and weight loss advice (34%). It seems when physicians do give advice, most of them follow the USPSTF guidelines by addressing nutrition and physical activity together.¹⁵

Providing advice alone did not predict a change in patient behavior. For instance, we found no significant association between dietary fat reduction and having received only nutrition advice. Possible explanations include the following:

Although physicians advised patients to reduce fat/cholesterol intake in 28% of conversations, they did so mostly in combination with other types of advice. Nutrition-only advice occurred in only 8% of conversations. Thus, there may have been insufficient power to detect the impact of this specific type of advice.
With nutrition-only advice, the most common recommendation was to reduce carbohydrates/sweets, which should not affect fat intake.

Advising patients solely on physical activity led to unintended weight gain overall. Other data have shown that exercise without dietary changes, though beneficial in many ways, is not substantially effective for weight loss.¹⁵ People may eat more when they exercise, either to reward themselves or to satiate increased appetite from increased energy expenditure. Or, if physicians recommend the standard goal of 150 minutes of intensive physical activity per week, normally sedentary patients may see that as unattainable and become too discouraged to try.^1,16,17

Combining types of advice seemed to help patients reduce their fat intake. Overall, however, simple, brief advice from a physician may not be enough to promote healthy lifestyle changes.

Also notable was that physicians rarely provided referrals, even though this is a strong recommendation from the National Institutes of Health, the American Diabetes Association, and the USPSTF.^1,16,17 It could be that many physicians believe referrals are not covered by insurance. Yet, the low frequency of referrals may suggest an important missing component of weight loss therapy, especially given that physician advice alone seems an inadequate intervention.

Avoid physician-centered appeals. Advice was often given in a physician-centered way. There are 3 possible explanations for such phrasing:

In the absence of clear evidence about how to deliver weight loss advice, physicians may be formulating advice based on their personal or clinical experiences.
Physicians either assume or sense that patients lack internal motivation to make lifestyle changes for themselves and instead request that patients make changes for the doctor-patient relationship.
Physicians might be trying to invoke authority in the hope that patients will respond accordingly.

Whatever the reason, the literature on self-centered physician talk indicates that patients are less satisfied when physicians make the visit more about themselves than about patients.¹⁸ A better strategy might be to use Motivational Interviewing¹⁹ that supports patient autonomy and attempts to elicit and build on internal motivation.