Primary Care

September 27th, 2009 by LHill Leave a reply »

Primary care practice in medicine does a very poor job of treating obesity. In a 2009 paper, researchers analyzed 696 million physician office visits of adults over 18 years old. In only 50% of these were both height and weight taken (so Body Mass Index could be determined) This was usually due to not taking the height measurement. Where a BMI was determined 27% of patients had normal weight, 31% were overweight and 37% were obese. Of the patients with obesity, a diagnosis of obesity was made in only 1/3 of the visits. In the patients with obesity, only 37% received counseling for diet, exercise or weight reduction. This percentage went up to 55% in patients who received a diagnosis of obesity. The researchers found the same pattern even when the patient with obesity had co-morbid conditions related to obesity. Adult obesity and office-based quality of care in …[Obesity (Silver Spring). 2009] – PubMed Result

Physician attitudes toward patients with obesity appear to be influenced by competency to treat, specialty and years since postgraduate training. Studies have shown that doctors can have stigmatizing attitudes to patients with obesity, believing such patients to not being able to benefit from counseling and have reported less desire to help obese patients. Implicit fat-bias has been found among health professionals treating obese patients. (See Fact Sheet on Stigma ) In a survey of School of Medicine faculty members, internal medicine faculty reported having the highest rate of obesity in their patients. Overall, physicians felt “fairly” competent in providing obesity counseling and reported an average of 14% of patient lost weight. 45% of physicians agreed that they have a negative reaction to the appearance of obese individuals which did not differ among specialties. Only about half felt qualified to treat obese patients; psychiatrists had the lowest sense of competency. More than half did not feel successful at treating obese patients with no difference between specialty. Physician success/efficacy was most strongly related to competency and patient weight loss. Pediatricians had a high expectation of a positive outcome but poorest weight loss in practice. Younger physicians had better expectations and outcomes than older physicians. Physicians’ attitudes about obesity and their asso…[BMC Health Serv Res. 2009] – PubMed Result

A complex set of factors may influence the physician’s decision to provide counseling, including judging the patient’s receptiveness to counseling, a ‘teachable moment,’ other medical matters, time and how many other patients are waiting to be seen. The art and complexity of primary care clinicians’…[Ann Fam Med. 2006 Jul-Aug] – PubMed Result

Another factor may be intentional neglect. In 1998 the editors of the prestigious New England of Medicine wrote an editorial in which they argued that weight loss was futile and dangerous and more so that treating obesity. They wrote, “In our view, doctors should provide advice if an overweight patient asks for help in planning a weight-loss program and recommend weight loss if a patient is suggering from health problems that can be ameliorated by weight loss, such as hypertension, diabetes or osteoarthritis, or it a patient is so obese that he or she is clearly in jeopardy (for example, if the patient is virtually immobilized.) In other situations, doctors should be cautious about exhorting patients to lose weight, especially when they are only mildly obese.” Losing weight–an ill-fated New Year’s resolution. [N Engl J Med. 1998] – PubMed Result The editorial produced a storm of reaction. William H. Dietz, MD, of the Centers for Disease Control and Prevention wrote prophetically, “This passive approach will not prevent weight gain in those at risk, nor will it prevent further weight gain in those who are already overweight. Furthermore, the rapid increase in body-mass index in the U.S. population who are overweight will most likely continue unabated if this passive approach is used. Because health care providers represent a trusted source of information about nutrition, we believe they should counsel all patients who are overweight to avoid further weight gain, regardless of whether their patients raise the issue of weight. Abundant data confirm that weight loss reduces obesity-associated morbidity. Delaying counseling until such a condition has developed reflects ineffective attempts at prevention and increases the likelihood that patients will rely on inappropriate or unhealthy methods of weight control.” The obesity problem. [N Engl J Med. 1998] – PubMed Result George L. Blackburn responded for the Massachusetts Medical Society Committee on Nutrition. They took issue with another statement from Dr. Angell in a February 9, 1998 Wall St. Journal that some people “just like to eat – an in that case it’s (obesity) no more a disease than bank robbery is a disease.” More on the obesity problem. [N Engl J Med. 1998] – PubMed Result

Childhood obesity is also poorly treated in primary care practices in the United States. This study reviewed many studies and found primary care physicians had negative feelings about dealing with childhood obesity. Primary care physicians’ knowledge, attitudes, bel…[Obes Rev. 2009] – PubMed Result

The Centers for Medicare and Medicaid undertook a large trial to see whether general prevention visits by Medicare beneficiaries resulted in improvements in smoking, alcohol consumption and sedentary lifestyle. There was not effect on sedentary behavior over two years. Medicare Lifestyle demonstration – PubMed Results

For more information, see

Reducing overweight and obesity: closing the gap b…[Fam Pract. 2008] – PubMed Result

Suboptimal identification of obesity by family phy…[Am J Manag Care. 2009] – PubMed Result

Health care providers perception of role Health care providers’ perceived role in changing …[Pediatrics. 2009] – PubMed Result

AHRQ Guidelines for Screening obesity in Adults Navigating the Health Care System: Ready to Lose Weight in the New Year? Experts Offer Guidance for Adults and Children