Obesity Counseling Often Shortchanged by Physician Time Constraints

By Sherree Geyer, contributor

June 26, 2012 - Hospitals and primary care practices that offer diet and activity counseling help patients to maintain a healthy weight and reduce the risks and costs related to increased morbidity and mortality. But many physicians don’t have the time to provide this beneficial counseling for their overweight patients, according to a new study.

A weighty issue

Current estimates from the Centers for Disease Control and Prevention (CDC) classify more than 35 percent of U.S. adults as obese with a weight-to-height body mass index (BMI) of 30 or more. Obesity increases the risk of heart disease, stroke, type 2 diabetes, hypertension, liver and gallbladder disease and cancer, leading to direct and indirect medical costs of $147 billion in 2008, according to CDC estimates.

Direct medical costs include preventive, diagnostic and treatment services; indirect costs include decreased productivity, restricted activity, absenteeism rates and bed days.

“Weight management, including diet and activity counseling programs, reduces costs because they lower overweight and obesity diseases. Complications are very low in cost compared to treating diseases, such as diabetes, and complications, such as heart attacks and strokes,” said Christine Gerbstadt, M.D., MPH, RD, LDN, CSSD, CDE, spokesperson for the Academy of Nutrition and Dietetics and author of Doctor's Detox Diet: The Ultimate Weight Loss Prescription.

The CDC reports that fewer than 5 percent of adults meet the physical activity (PA) recommendations set forth by the U.S. Department of Health and Human Services (HHS). According to 2008 HHS guidelines, adults should get at least 150 minutes of moderate- and 75 minutes of vigorous-intensity physical activity a week. Moderate activities include walking or biking; vigorous activities include jogging or running.

Where primary physicians weigh in

“Most primary care providers believe PA counseling is important and that they have a role in promoting PA among their patients,” according to a new article in the July 2012 issue of British Journal of Sports Medicine, “Primary Care Providers’ Perceptions of Physical Activity Counseling in a Clinical Setting: A Systematic Review.” But they don’t always provide that counseling in their clinical practices, due to a number of barriers identified by the authors’ systematic review of 19 published studies.

“There are quite a few barriers to incorporating it (PA) into practice but the biggest one by far is lack of time,” said lead author Emily T. Hébert, MPH, from the University of Texas, School of Public Health. She and her co-authors found that other top barriers included lack of knowledge and training, and poor success in behavioral modification.

The authors estimate that 30 percent to 50 percent of U.S. physicians regularly provide physical activity counseling to their patients, finding that “Providers are more likely to counsel their patients about PA if they are active themselves or feel their patients’ condition, such as cardiovascular disease or obesity, would strongly benefit from a lifestyle change.”

“Unless weight and activity are specifically related to the patient’s complaint, they (physicians) are not going to address it,” said Hébert.

Bringing other practitioners into the picture

Fewer nurses than physicians rate the same barriers as major impediments to nutrition and activity counseling because, as Hébert noted, “Nurses felt they had more time to spend with patents than docs” and “counseling can be included with duties they already do.”

Gerbstadt conceded, “Physicians have precious little time with patients in most practice models.” She believes, however, that the time barrier “can be alleviated by using registered dieticians and diet technicians to provide dietary counseling and exercise specialists to offer fitness programs.”

In fact, Hébert’s team from the UT School of Public Health found that referrals to counseling professionals for health promotion or use of other healthcare workers to deliver counseling instead of or in addition to physicians was an effective option, and produced the best long-term results in patient behavior. To provide more training and knowledge to physicians, they suggest including health promotion counseling into medical school curricula.

“Physicians need to incorporate this advice into everyday practice to prevent these (health) issues,” Hébert said. “It’s better to hit these problems before they start.”

Helping patients set long- and short-term goals improves the odds of weight loss and management success, added Gerbstadt. “A realistic goal may be 30 pounds for the long term, but the interim goals may be one pound a week or six pounds a month.”

“For someone who does not have much activity, add 10 minutes a day for five days a week to start. That’s only 50 minutes a week,” she explained.

And this physical activity counseling shouldn’t be limited to adult patients.

“There’s a huge focus on childhood obesity,” explained Hébert, who believes that “support starts early with kids. That’s when they start developing habits.”

As part of the movement to fight childhood obesity--which currently affects almost 1 in 5 children--the American Medical Association (AMA) recently announced its support of legislation requiring nutrition education classes in the first through 12th grades.  The American Academy of Pediatrics also includes a number of resources to help educate and counsel children and parents about childhood obesity on their website.