Patient Education and Counseling 97 (2014) 82–87
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Patient Education and Counseling journal homepage: www.elsevier.com/locate/pateducou
Provider Perspectives
A qualitative inquiry about weight counseling practices in community health centers Gillian L. Schauer a,*, Rebecca C. Woodruff a, James Hotz b, Michelle C. Kegler a a b
Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, Atlanta, USA Albany Area Primary Health Care, Albany, USA
A R T I C L E I N F O
A B S T R A C T
Article history: Received 5 February 2014 Received in revised form 23 May 2014 Accepted 30 May 2014
Objective: To use qualitative methods to explore how clinicians approach weight counseling, including who they counsel, how they bring up weight, what advice they provide, and what treatment referral resources they use. Methods: Thirty primary care physicians, physician assistants, and nurse practitioners from four multiclinic community health center systems (CHCs) in the state of Georgia (U.S.) completed one-on-one semi-structured interviews. Interviews were digitally recorded, transcribed verbatim, and coded. Results: Clinicians report addressing weight with those who have weight-related chronic conditions, are established patients, or have a change in weight since the previous visit. Most clinicians address weight in the context of managing or preventing chronic conditions. Clinicians report providing detailed dietary advice to patients, including advice about adding or avoiding foods. Many clinicians base advice on their own experiences with weight. Most report no community-based resources to offer patients for weight loss. In the absence of resources, clinicians develop or use existing brochures, refer to in-house weight programs, or use online resources. Conclusion: Clinicians use a variety of approaches for addressing weight, many of which are not evidence-based. Linkages with weight loss resources in the health care system or community are not widely reported. Implications for practice: Clinicians and others from the primary care team should continue to offer weight-related counseling to patients with obesity, however, evidence-based treatment approaches for weight loss may need to be adapted or expanded for the CHC practice environment. ß 2014 Elsevier Ireland Ltd. All rights reserved.
Keywords: Obesity Qualitative methods Clinician counseling Community health centers Primary care
1. Introduction Two out of three Americans are overweight or obese [1], with significant disparities existing among racial/ethnic minority [2] and rural [3,4] populations. International obesity rates are similar, with the worldwide prevalence of obesity nearly doubling between 1980 and 2008 [5]. Obesity increases the risk of heart disease, diabetes, cancer, hypertension, stroke, liver or gallbladder disease, arthritis, and other respiratory diseases [6], making it an important public health issue to address. The health care system is an increasingly important setting in which to address weight. Americans visit a health professional an average of four times per year [7], providing an opportunity for
* Corresponding author at: Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, 1518 Clifton Road NE, GCR 430, Atlanta, GA 30322, USA. Tel.: +1 206 819 9391; fax: +1 404 727 1369. E-mail address: [email protected] (G.L. Schauer). http://dx.doi.org/10.1016/j.pec.2014.05.026 0738-3991/ß 2014 Elsevier Ireland Ltd. All rights reserved.
routine interventions to promote weight-loss behaviors like diet and exercise. Primary care settings like Community Health Centers (CHCs) comprise the nation’s health care safety net, and serve around 25 million patients, many of whom are low income [8]. The Patient Protection and Affordable Care Act (ACA), signed into law in the U.S. in 2010, is anticipated to significantly increase health care coverage, resulting in increased primary care visits, particularly among low-income and minority individuals [9,10]. Furthermore, a number of provisions in the ACA, including the elimination of patient costs related to obesity screening and counseling, provide a natural opportunity for primary care to take a more central role in addressing weight [11]. While obesity is a major cause of preventable death and disease, few interventions have been shown to be effective in promoting and sustaining weight loss [12]. Behavioral counseling delivered by clinicians can motivate changes to diet and physical activity and has been significantly associated with patient weight-loss and weight-loss attempts [13]. A number of practice guidelines now recommend that clinicians provide intensive counseling for obese
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patients [14,15]. However, the intensive interventions recommended by the guidelines are often not possible in primary care settings due to a variety of clinician, patient, and environmental factors [16–18]. Studies suggest that fewer than half of obese patients report receiving clinician advice to lose weight, modify their diet, or increase exercise [19–21]. When counseling does occur, it often lacks the provision of specific weight-loss strategies. For example, one study found that only 5% of patients who reported discussing their weight with a provider received advice about diet and exercise strategies [22]. In CHCs, 34% of overweight or obese patients reported receiving some weight management counseling from their provider, but only about 15% received referral to a nutritionist [23]. While a number of quantitative surveys have measured the frequency and quality of weight-related counseling in primary care, few have focused on understanding clinician’s perspectives about their practice decisions [18]. Qualitative research methods can be used to describe complexities of weight counseling that cannot be captured through closed-ended surveys. While some weight-related qualitative studies have recently been conducted with clinicians, most have focused on pediatric obesity issues [24–26] or have been conducted outside of the U.S. [27,28]. Furthermore, few studies have focused on weight counseling practices in CHCs. Accordingly, this study sought to explore how clinicians approach weight counseling in adults, including who they counsel, how they bring up weight, what advice they provide, and what treatment referral resources they use.
2. Methods 2.1. Recruitment and sampling Thirty-two primary care clinicians were recruited from four multi-clinic community health center systems (CHCs) in Georgia to participate in one-on-one in-depth interviews. Two interviews were excluded from these analyses as they pertained only to pediatric weight counseling, and themes were substantially different from those of clinicians providing care primarily to adults. The four multi-clinic CHCs that Emory University partnered with for recruitment comprised more than 30 individual clinics, many of which were located in rural areas and served a high proportion of African-American patients. Eligible clinicians were recruited by email and had to be either physicians, physician assistants, or nurse practitioners; practice at one of the four CHC systems that Emory partnered with for this study; and speak and understand English. The Emory Institutional Review Board approved this study. 2.2. Interviews and measures One-on-one semi-structured interviews were conducted with participating clinicians via telephone or in person, depending on their preference. Interviews were digitally recorded and lasted between 25 and 48 min (average 34 min). Clinic leadership (e.g., CEOs, clinical directors, quality managers) at participating CHC systems provided input on the initial interview guide. Topics included asking clinicians to describe how and when they bring up the topic of weight with obese patients; what they say to them about it; how patients respond; what specific tools, strategies or resources they offer patients; what barriers or facilitators impact their counseling; and how they describe a successful weight counseling encounter. Participants also provided demographic information. Participants received a $25 gift card incentive for participating in the study.
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2.3. Analysis Audio-recordings of the interviews were de-identified and transcribed verbatim. Transcripts were coded in MaxQDA (Version 10, 2013, VERBI Software, Berlin, Germany). An initial codebook was developed by reading a selection of transcripts and identifying both deductive and inductive themes. The codebook was further refined by having two researchers (GLS and RCW) separately code and compare codes from six transcripts. Discrepancies in coding were resolved through discussion and codes were amended or added to the codebook accordingly. One coder then coded all transcripts (GLS), with a second member of the team (RCW) coding every third transcript to ensure appropriate application of the codes. Findings were validated by reviewing the codebook and sampling representative quotes with the entire team. 3. Results 3.1. Demographics Participants for this study were slightly more likely to be female than male (53.3% vs. 46.7%). Most participants (43.3%) were between the age of 36 and 45; 66.7% were white, 16.7% were black, 10.0% were Asian, and 6.6% were Hispanic (Table 1). Nearly half were physicians (46.7%), with 36.7% being physician assistants, and 16.6% being nurse practitioners (Table 1); 40.0% provided care to adults only, and 60.0% provided care to both children and adults. The number of years participants had been practicing medicine ranged from one year to 37 years (mean = 13.3 years), with 40.0% practicing less than 10 years, 40.0% practicing between 10 and 20 years, and 20.0% practicing more than 20 years. No substantial differences in themes were found based on number of years in practice. 3.2. When and to whom clinicians counsel about weight Many clinicians initially reported that they addressed weight with all patients. However, upon further discussion, a majority
Table 1 Participant demographics. n (%) or mean (SD) Sex (%) Male Female Race (%) White, non-Hispanic Black, non-Hispanic Asian, non-Hispanic Hispanic Age (in years) (%) 18–35 36–45 46–55 56–65 Clinician type (%) Physician Physician assistant Nurse practitioner Provide care for (%) Adults only Both children and adults Years practicing medicine Range (in years) Mean (SD) 20 years
14 (46.7%) 16 (53.3%) 20 5 3 2
(66.7%) (16.7%) (10.0%) (6.6%)
6 13 3 8
(20.0%) (43.3%) (10.0%) (26.7%)
14 (46.7%) 11 (36.7%) 5 (16.6%) 12 (40.0%) 18 (60.0%) 1–37 13.3 (10.9) 12 (40.0%) 12 (40.0%) 6 (20.0%)
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described certain unwritten protocols for when they decided to address weight with a patient. Clinicians reported addressing weight with established patients with whom they had an existing rapport, versus addressing weight with new or unfamiliar patients. As described by a clinician, ‘‘If it’s the first time I’ve seen a patient, I’m usually not going to discuss weight because I don’t want to get off on the wrong foot with them. But if they come back and they’re an established patient and they’ve gotten a chance to know me and I don’t think I’ll be too offensive by bringing it up, then I’ll bring it up.’’ Similarly, clinicians described addressing weight among patients with weight-related chronic or comorbid conditions versus those who had acute issues that were not perceived to be weight related. For example, one clinician said, ‘‘Well, if I’m seeing a patient for acute care, I typically don’t address the weight then, unless I feel that it’s contributing to their acute care problem.’’ Another clinician described why they did not address weight in acute situations: ‘‘They [patients] can get a little offended when you bring it up especially if it has nothing to do with what they came in for. If they came in and they said they had a cold, to go from, ‘here’s your cough medicine, make sure you get some rest,’ into, ‘you need to be getting more exercise,’ it doesn’t always go over very well.’’ By contrast, a clinician said: ‘‘If it’s an obesity related issue, perhaps like they’re diabetic and the blood pressure is out of control that day, we actually discuss obesity and how it is affecting them, along with the high blood pressure.’’ Some clinicians also reported addressing weight with those who had gained or lost weight since their last visit, patients who were younger, and patients who had stable health. A number of clinicians talked about depression and weight gain, stating that they tried to address the depression with patients before talking about weight loss, due to the sensitivity of the topic. Some clinicians also talked about basing their decision to address weight on the patient’s ‘‘readiness to change’’ or awareness of the problem. One clinician described this: ‘‘I try to identify when the patient is: (1) comfortable with me as a provider and (2) when I see the signs that they are at a point health wise when they’re ready [to change], because they have to see the benefit to their health. . .’’ 3.3. How clinicians bring up the topic of weight with patients Overwhelmingly, clinicians reported bringing up weight as part of discussions about weight-related chronic conditions, or as part of discussions about other vital signs. For example, one clinician said, ‘‘Generally when reviewing their vitals, I look at their weight and compare the weight today and the weight at the previous date. That’s when it becomes a discussion point.’’ Another clinician said, ‘‘It comes up in the context of managing several of their medical conditions. If their blood sugar is up, but their weight is up 10 pounds, I will tell them that it’s very difficult to manage the blood sugar without managing the diet and the weight, because as the weight goes up, the insulin and other management requirements are going to change.’’ Many clinicians reported using chronic conditions or vital signs to introduce the topic of weight because it provided a less stigmatizing way to address the issue. As one clinician said when asked about using chronic diseases to bring up the topic, ‘‘[Patient are] more responsive. They don’t get offended, like you’re trying to call them fat. People don’t want to hear that terminology, they already feel bad anyway. You have to come at it at a different angle.’’ Clinicians also reported linking weight to worsening chronic conditions to get patient’s attention. For example, one clinician said, ‘‘I just let them know that there are ways that we can prevent [them] from having a heart attack and stroke, you know, or prevent kidney disease and dialysis. And when you say dialysis to a diabetic, they understand. They look at you like, ‘Oh Lord, no. I can’t have that,’ because they know what that means.’’
A number of clinicians also reported bringing up weight when talking about decreasing medications. A clinician described telling patients, ‘‘We can decrease your medicine and eventually take you off [of it] if you were to eat better and exercise,’’ noting that most patients don’t want to take more medicine or start insulin. Some clinicians also reported that patients bring up weight on their own, making it easier to talk about it: ‘‘A lot of times the patient brings it [weight] up herself or himself saying that, ‘I need to do something about this weight.’ And, if they bring it up, that’s great because I can give them guidelines on it.’’ While a majority of clinicians reported being sensitive about when and how they brought up weight with obese patients, a few clinicians reported being direct and to the point about it. For example, one clinician said, ‘‘I’ll just usually say straightforward, ‘You need to lose some weight,’’’ while another said, ‘‘I think [we] are socially too sensitive about weight. I like to bring it from a little bit harsher standpoint.’’ The few clinicians who reported taking this approach tended to be physicians and tended to be male. They also described an awareness that this direct approach did not necessarily yield positive patient reactions. For example, one clinician said, ‘‘I’m not everybody’s cup of tea. I believe in honesty. I believe in helping you to identify what the issues are when it comes to your health. And then saying to you this is where we are. . .Unfortunately, not everybody wants to talk about [that].’’ 3.4. What do clinicians say to patients about their weight? All clinicians reported offering patients dietary advice and/or advice about physical activity, and a few reported advising patients about specific weight loss goals. 3.4.1. Dietary advice Clinicians reported providing a wide variety of dietary advice to patients, with the majority reporting they advise patients to avoid or add certain food to their diet. Clinicians talked about asking patients to avoid soda or sugar-sweetened beverages, fried foods, and processed foods. For example, one clinician described asking patients about soda consumption by saying, ‘‘How many sodas are you having a day? Well, you know what, let’s cut that down and have one less each day.’’ Another clinician described asking them to avoid processed foods: ‘‘I ask them to try to avoid processed food and then we talk about what processed foods mean – it’s the stuff in boxes, stuff with a long shelf life, has a lot of chemicals in it. And I usually tell them to try to think about how their great grandmother might have cooked – fresh fruits, vegetables. . . I always try to tell them to try to avoid the processed things – the longer the shelf life, the shorter you’ll live.’’ Advice about adding foods was not always consistent among clinicians. For example, some clinicians described advising patients to add complex carbohydrates to their meals, while others reported advising patients to limit all carbohydrates to lose weight. Most clinicians reported asking patients to add more fruits and vegetables to their diet. Often clinicians talked about advising patients to avoid one type of food while adding another, for example, ‘‘I tell them, ‘I want you to avoid sugar as much as possible, try to eat more complex carbohydrates.’ And I explain what a complex carbohydrate is, like ‘eat brown foods, nothing white’.’’ In addition to adding or avoiding certain foods, some clinicians also talked about advising patients to drink more water, eat breakfast, prepare foods at home (vs. buying prepared food), or eat smaller meals. Lastly, many clinicians reported advising patients to following a specific diet or dietary approach (e.g., low carb, low sugar, low fat), though these approaches differed widely among clinicians.
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3.4.2. Advice about physical activity Clinicians were less likely to describe detailed advice given to patients about physical activity. While physical activity was mentioned in almost every interview, it was typically general (e.g., ‘‘I tell them to get some physical activity.’’). When probing about physical activity advice, some barriers emerged, including that patients were often too obese to exercise, or did not have access to gyms or physical activity equipment. Walking was the most common physical activity strategy addressed. A few clinicians specified that they work with individuals to set small physical activity goals and increase them over time or even demonstrate exercises in their office. 3.4.3. Advice specifically about weight loss Only a few clinicians reported talking to patients about losing a specific amount of weight. In these cases, some clinicians said they provide patients with an overall weight goal, and some clinicians reported breaking up the higher weight goal into smaller increments or suggesting their patient focus on trying to lose ‘‘one to two pounds per week.’’ 3.5. What treatment resources do clinicians offer patients for weight loss? An overwhelming majority of clinicians interviewed reported that they did not have any external behavioral treatment resources (e.g., dietician, class, program) to offer patients who wanted to or needed to lose weight, either because resources were not available in their area, or because resources were too costly for patients to be able to access. Only two clinicians reported that they had available and reliable local resources for patients. Both of these clinicians practiced in a more metropolitan area. If clinicians had resources, most seemed to be for people with diabetes. If these were the only resources available to patients, some clinicians reported using them for those without diabetes too, ‘‘We don’t have a lot of resources to refer people to. Here, we have a diabetic education class that focuses on all aspects of diabetes and a lot of nutritional aspects; that meets every two months. I refer the patients to that even if they’re not a diabetic.’’ In the absence of available resources, clinicians develop or use existing brochures or handouts, refer patients to in-house weight programs, or use online resources. Brochures or handouts seemed to be the most common treatment resource, however the subject matter and type of handouts seemed to vary widely. While some handouts described were from established organizations (e.g., the American Diabetes Association, the Food and Drug Administration), others were created by the clinicians based on their own research and knowledge. For example, one clinician said, ‘‘I came up with my own little list of things that [patients] can use to make small changes, and I hand it to them [during the visit]. It’s a list of 15 things.’’ Clinicians also reported sending patients to online resources. These varied widely and included suggesting patients conduct a Google search; sending patients to websites with calorie counting apps and recipes; and sending patients to federal and commercial websites like choosemyplate.gov, the Biggest Loser website, or the Forks Over Knives website. Only a few clinicians reported having in-house weight loss programs. In all cases, they were developed by a physician at the clinic who had a particular interest in weight counseling. In most cases, the programs were also linked to ongoing monitoring or weight loss medications. While most clinicians said patients routinely ask for medications or other ‘‘quick fix’’ solutions, only a small number were willing to prescribe and monitor weight loss medication. Similarly, only a few clinicians reported referring obese patients for surgery.
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3.6. Basing advice and treatment on personal experience Many clinicians said the advice and treatment they offered patients was based on their own experience with weight. For example, when talking about advising patients to buy healthy foods, one clinician said, ‘‘I tell them my own experience, I’m like, ‘Listen, when I go in the grocery store, I want to go down that cookie aisle too. But I don’t do it because I know if I bring it home, I’m going to eat all of it.’ I make it kind of personal.’’ When talking about exercise, another clinician said, ‘‘I hate treadmills, stationary bikes, and exercise machines because all I do is watch the clock and see how far I go. It’s easier to say, ‘I need to do 5 more [minutes] than the 5 I already did’ than to say, ‘I need to stay on this for 30 minutes’. I approach my own life that way, in bite size pieces, and it works for me. So I just feel like it would work for my patients.’’ Both clinicians who reported having successfully lost weight, and those who had not, used this strategy. Clinicians seemed to agree that sharing their own experience would help build rapport with patients. For example, one clinician said: ‘‘I have a unique approach, because I, myself, went through weight loss a couple years ago. I managed to lose 45–50 pounds through exercise and through eating right and counting calories. So I know how difficult it is to lose weight, I know how difficult it is to change how you eat, I know how difficult it is to get up and exercise for an hour every single day. And so I feel like I have a connection with individuals that really want to lose weight.’’ Another clinician said, ‘‘Well I do not have an optimal BMI myself, so I usually say, ‘well it looks like 100% of the people in this room need to work on their diet and exercise some more.’ And because I know that the patients have been to other doctors who usually look down their nose and tell them they need to lose weight and those doctors are usually the ones with BMI’s of 23, I try my best to sympathize with the patient.’’ 4. Discussion and conclusion 4.1. Discussion This study is among the first to elicit qualitative information from primary care clinicians in CHCs about how they approach weight loss counseling with adult patients; prior qualitative studies in this area have included CHCs, but have not exclusively focused on the CHC setting [18]. Important findings from this study include the reported lack of available or accessible weight-related treatment or referral resources for adult patients, including a lack of internal clinic-based resources like nutritionists and health coaches, or low-cost external resources like weight loss programs or exercise programs that could provide more intensive behavioral treatment. In the absence of these resources, clinicians provide patients with varied advice and treatment, much of which is based on their own experiences or personal knowledge rather than evidence-based practice. More research is needed to assess why evidence-based treatment approaches are not used in the absence of available and credible external referral resources. It may be that clinicians lack adequate time and training to provide patients with evidencebased dietary, physical activity, and weight loss approaches. Still, it is promising that clinicians in this study reported regularly addressing weight in the absence of treatment resources; other studies have found that clinicians base their decision to address weight on whether or not weight-loss programs exist for patients in the community [18]. No other study that we are aware of has found that clinicians use their own experience with weight when counseling patients. Future studies should seek to assess how common this approach is, and whether or not it makes patients more receptive to discussions about weight.
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Findings suggest some common approaches that were shared by most clinicians. For example, a majority of clinicians we interviewed reported addressing weight with established patients with whom they had rapport or with patients who had weight-related chronic diseases. These findings are consistent with research that suggests that clinicians may determine whether or not to address weight with obese patients based on their own perceptions about the success of the intervention, the availability of treatment resources, the patient’s receptivity to the counseling, and the presence of a teachable moment like a weightrelated disease [18]. Clinicians also reported addressing weight in the context of related chronic disease. A previous study found that weight-related chronic conditions offer a teachable moment to address weight-related behaviors [18]. These data suggest that clinicians offer patients specific advice about dietary changes they can make. This finding is contrary to previous data suggesting that weight loss counseling often lacks the provision of specific changes patients could make to diet [29]. However, these data suggest that specific advice about physical activity was rarely provided. This may be because patients were perceived to be uninterested in or unable to be physically active. More research is needed to determine possible barriers clinicians face in the provision of advice about physical activity. 4.2. Implications for practice These data have important implications for practice. First, evidence-based treatment approaches may need to be detailed or adapted to meet the needs of the over-burdened primary care clinician. More research is needed to identify appropriate interventions that can be used in CHCs; a majority of the evidence-base in obesity counseling and treatment comes from other practice settings. Second, identifying new clinical team members, such as health coaches or dieticians, and training them to provide more intensive weight counseling to patients could support primary care clinicians. However, if the use of ancillary care providers is recommended, clinics may need financial support and incentives to be able to staff these individuals. These positions could be created and reimbursed as part of the patient centered medical home (PCMH). Effective weight management and physical activity counseling should be incentivized as important quality measures for a PCMH. Third, findings suggest that community-clinic linkages have not been created consistently in CHCs; public health efforts should focus on working with communities and clinics to create easy access (both for patients and for clinicians) to evidence-based referral resources [16], and on identifying appropriate incentives to motivate patients to use identified resources. Finally, electronic health records could also be leveraged to provide clinicians with decision support prompts, facilitating more evidence-based interactions in the clinic. 4.3. Limitations The following limitations should be considered when interpreting results from this study. First, these findings are from clinicians at CHCs in the southeastern U.S. It is unclear whether similar themes exist among clinicians practicing in other regions of the country. Second, these data are qualitative, and cannot be used to make broad inferences about the beliefs or behaviors of a larger clinician population. Rather these findings suggest possible behavioral and contextual reasons why clinicians may address weight inconsistently with patients. Third, our findings are based on self-reports from clinicians and do not include direct observation or discussions with patients.
4.4. Conclusion Findings suggest that clinicians at CHCs in Georgia are using a variety of approaches to address weight, but lack sufficient tools, staff, and resources to support their efforts. Increased availability of evidence-based referral resources, use of decision support tools, and clinical team training could be used improve weight counseling in CHCs. Funding The qualitative study described in this manuscript was funded by Cooperative Agreement Number 1U48DP0010909-01-1 from the Centers for Disease Control and Prevention and the National Cancer Institute. The contents of this article are solely the responsibility of the authors and do not necessarily represent the official views of the CDC or NCI. Conflict of interest The authors do not have any conflicts of interest to report.
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Contents lists available at ScienceDirect
Patient Education and Counseling journal homepage: www.elsevier.com/locate/pateducou
Provider Perspectives
A qualitative inquiry about weight counseling practices in community health centers Gillian L. Schauer a,*, Rebecca C. Woodruff a, James Hotz b, Michelle C. Kegler a a b
Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, Atlanta, USA Albany Area Primary Health Care, Albany, USA
A R T I C L E I N F O
A B S T R A C T
Article history: Received 5 February 2014 Received in revised form 23 May 2014 Accepted 30 May 2014
Objective: To use qualitative methods to explore how clinicians approach weight counseling, including who they counsel, how they bring up weight, what advice they provide, and what treatment referral resources they use. Methods: Thirty primary care physicians, physician assistants, and nurse practitioners from four multiclinic community health center systems (CHCs) in the state of Georgia (U.S.) completed one-on-one semi-structured interviews. Interviews were digitally recorded, transcribed verbatim, and coded. Results: Clinicians report addressing weight with those who have weight-related chronic conditions, are established patients, or have a change in weight since the previous visit. Most clinicians address weight in the context of managing or preventing chronic conditions. Clinicians report providing detailed dietary advice to patients, including advice about adding or avoiding foods. Many clinicians base advice on their own experiences with weight. Most report no community-based resources to offer patients for weight loss. In the absence of resources, clinicians develop or use existing brochures, refer to in-house weight programs, or use online resources. Conclusion: Clinicians use a variety of approaches for addressing weight, many of which are not evidence-based. Linkages with weight loss resources in the health care system or community are not widely reported. Implications for practice: Clinicians and others from the primary care team should continue to offer weight-related counseling to patients with obesity, however, evidence-based treatment approaches for weight loss may need to be adapted or expanded for the CHC practice environment. ß 2014 Elsevier Ireland Ltd. All rights reserved.
Keywords: Obesity Qualitative methods Clinician counseling Community health centers Primary care
1. Introduction Two out of three Americans are overweight or obese [1], with significant disparities existing among racial/ethnic minority [2] and rural [3,4] populations. International obesity rates are similar, with the worldwide prevalence of obesity nearly doubling between 1980 and 2008 [5]. Obesity increases the risk of heart disease, diabetes, cancer, hypertension, stroke, liver or gallbladder disease, arthritis, and other respiratory diseases [6], making it an important public health issue to address. The health care system is an increasingly important setting in which to address weight. Americans visit a health professional an average of four times per year [7], providing an opportunity for
* Corresponding author at: Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, 1518 Clifton Road NE, GCR 430, Atlanta, GA 30322, USA. Tel.: +1 206 819 9391; fax: +1 404 727 1369. E-mail address: [email protected] (G.L. Schauer). http://dx.doi.org/10.1016/j.pec.2014.05.026 0738-3991/ß 2014 Elsevier Ireland Ltd. All rights reserved.
routine interventions to promote weight-loss behaviors like diet and exercise. Primary care settings like Community Health Centers (CHCs) comprise the nation’s health care safety net, and serve around 25 million patients, many of whom are low income [8]. The Patient Protection and Affordable Care Act (ACA), signed into law in the U.S. in 2010, is anticipated to significantly increase health care coverage, resulting in increased primary care visits, particularly among low-income and minority individuals [9,10]. Furthermore, a number of provisions in the ACA, including the elimination of patient costs related to obesity screening and counseling, provide a natural opportunity for primary care to take a more central role in addressing weight [11]. While obesity is a major cause of preventable death and disease, few interventions have been shown to be effective in promoting and sustaining weight loss [12]. Behavioral counseling delivered by clinicians can motivate changes to diet and physical activity and has been significantly associated with patient weight-loss and weight-loss attempts [13]. A number of practice guidelines now recommend that clinicians provide intensive counseling for obese
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patients [14,15]. However, the intensive interventions recommended by the guidelines are often not possible in primary care settings due to a variety of clinician, patient, and environmental factors [16–18]. Studies suggest that fewer than half of obese patients report receiving clinician advice to lose weight, modify their diet, or increase exercise [19–21]. When counseling does occur, it often lacks the provision of specific weight-loss strategies. For example, one study found that only 5% of patients who reported discussing their weight with a provider received advice about diet and exercise strategies [22]. In CHCs, 34% of overweight or obese patients reported receiving some weight management counseling from their provider, but only about 15% received referral to a nutritionist [23]. While a number of quantitative surveys have measured the frequency and quality of weight-related counseling in primary care, few have focused on understanding clinician’s perspectives about their practice decisions [18]. Qualitative research methods can be used to describe complexities of weight counseling that cannot be captured through closed-ended surveys. While some weight-related qualitative studies have recently been conducted with clinicians, most have focused on pediatric obesity issues [24–26] or have been conducted outside of the U.S. [27,28]. Furthermore, few studies have focused on weight counseling practices in CHCs. Accordingly, this study sought to explore how clinicians approach weight counseling in adults, including who they counsel, how they bring up weight, what advice they provide, and what treatment referral resources they use.
2. Methods 2.1. Recruitment and sampling Thirty-two primary care clinicians were recruited from four multi-clinic community health center systems (CHCs) in Georgia to participate in one-on-one in-depth interviews. Two interviews were excluded from these analyses as they pertained only to pediatric weight counseling, and themes were substantially different from those of clinicians providing care primarily to adults. The four multi-clinic CHCs that Emory University partnered with for recruitment comprised more than 30 individual clinics, many of which were located in rural areas and served a high proportion of African-American patients. Eligible clinicians were recruited by email and had to be either physicians, physician assistants, or nurse practitioners; practice at one of the four CHC systems that Emory partnered with for this study; and speak and understand English. The Emory Institutional Review Board approved this study. 2.2. Interviews and measures One-on-one semi-structured interviews were conducted with participating clinicians via telephone or in person, depending on their preference. Interviews were digitally recorded and lasted between 25 and 48 min (average 34 min). Clinic leadership (e.g., CEOs, clinical directors, quality managers) at participating CHC systems provided input on the initial interview guide. Topics included asking clinicians to describe how and when they bring up the topic of weight with obese patients; what they say to them about it; how patients respond; what specific tools, strategies or resources they offer patients; what barriers or facilitators impact their counseling; and how they describe a successful weight counseling encounter. Participants also provided demographic information. Participants received a $25 gift card incentive for participating in the study.
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2.3. Analysis Audio-recordings of the interviews were de-identified and transcribed verbatim. Transcripts were coded in MaxQDA (Version 10, 2013, VERBI Software, Berlin, Germany). An initial codebook was developed by reading a selection of transcripts and identifying both deductive and inductive themes. The codebook was further refined by having two researchers (GLS and RCW) separately code and compare codes from six transcripts. Discrepancies in coding were resolved through discussion and codes were amended or added to the codebook accordingly. One coder then coded all transcripts (GLS), with a second member of the team (RCW) coding every third transcript to ensure appropriate application of the codes. Findings were validated by reviewing the codebook and sampling representative quotes with the entire team. 3. Results 3.1. Demographics Participants for this study were slightly more likely to be female than male (53.3% vs. 46.7%). Most participants (43.3%) were between the age of 36 and 45; 66.7% were white, 16.7% were black, 10.0% were Asian, and 6.6% were Hispanic (Table 1). Nearly half were physicians (46.7%), with 36.7% being physician assistants, and 16.6% being nurse practitioners (Table 1); 40.0% provided care to adults only, and 60.0% provided care to both children and adults. The number of years participants had been practicing medicine ranged from one year to 37 years (mean = 13.3 years), with 40.0% practicing less than 10 years, 40.0% practicing between 10 and 20 years, and 20.0% practicing more than 20 years. No substantial differences in themes were found based on number of years in practice. 3.2. When and to whom clinicians counsel about weight Many clinicians initially reported that they addressed weight with all patients. However, upon further discussion, a majority
Table 1 Participant demographics. n (%) or mean (SD) Sex (%) Male Female Race (%) White, non-Hispanic Black, non-Hispanic Asian, non-Hispanic Hispanic Age (in years) (%) 18–35 36–45 46–55 56–65 Clinician type (%) Physician Physician assistant Nurse practitioner Provide care for (%) Adults only Both children and adults Years practicing medicine Range (in years) Mean (SD) 20 years
14 (46.7%) 16 (53.3%) 20 5 3 2
(66.7%) (16.7%) (10.0%) (6.6%)
6 13 3 8
(20.0%) (43.3%) (10.0%) (26.7%)
14 (46.7%) 11 (36.7%) 5 (16.6%) 12 (40.0%) 18 (60.0%) 1–37 13.3 (10.9) 12 (40.0%) 12 (40.0%) 6 (20.0%)
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described certain unwritten protocols for when they decided to address weight with a patient. Clinicians reported addressing weight with established patients with whom they had an existing rapport, versus addressing weight with new or unfamiliar patients. As described by a clinician, ‘‘If it’s the first time I’ve seen a patient, I’m usually not going to discuss weight because I don’t want to get off on the wrong foot with them. But if they come back and they’re an established patient and they’ve gotten a chance to know me and I don’t think I’ll be too offensive by bringing it up, then I’ll bring it up.’’ Similarly, clinicians described addressing weight among patients with weight-related chronic or comorbid conditions versus those who had acute issues that were not perceived to be weight related. For example, one clinician said, ‘‘Well, if I’m seeing a patient for acute care, I typically don’t address the weight then, unless I feel that it’s contributing to their acute care problem.’’ Another clinician described why they did not address weight in acute situations: ‘‘They [patients] can get a little offended when you bring it up especially if it has nothing to do with what they came in for. If they came in and they said they had a cold, to go from, ‘here’s your cough medicine, make sure you get some rest,’ into, ‘you need to be getting more exercise,’ it doesn’t always go over very well.’’ By contrast, a clinician said: ‘‘If it’s an obesity related issue, perhaps like they’re diabetic and the blood pressure is out of control that day, we actually discuss obesity and how it is affecting them, along with the high blood pressure.’’ Some clinicians also reported addressing weight with those who had gained or lost weight since their last visit, patients who were younger, and patients who had stable health. A number of clinicians talked about depression and weight gain, stating that they tried to address the depression with patients before talking about weight loss, due to the sensitivity of the topic. Some clinicians also talked about basing their decision to address weight on the patient’s ‘‘readiness to change’’ or awareness of the problem. One clinician described this: ‘‘I try to identify when the patient is: (1) comfortable with me as a provider and (2) when I see the signs that they are at a point health wise when they’re ready [to change], because they have to see the benefit to their health. . .’’ 3.3. How clinicians bring up the topic of weight with patients Overwhelmingly, clinicians reported bringing up weight as part of discussions about weight-related chronic conditions, or as part of discussions about other vital signs. For example, one clinician said, ‘‘Generally when reviewing their vitals, I look at their weight and compare the weight today and the weight at the previous date. That’s when it becomes a discussion point.’’ Another clinician said, ‘‘It comes up in the context of managing several of their medical conditions. If their blood sugar is up, but their weight is up 10 pounds, I will tell them that it’s very difficult to manage the blood sugar without managing the diet and the weight, because as the weight goes up, the insulin and other management requirements are going to change.’’ Many clinicians reported using chronic conditions or vital signs to introduce the topic of weight because it provided a less stigmatizing way to address the issue. As one clinician said when asked about using chronic diseases to bring up the topic, ‘‘[Patient are] more responsive. They don’t get offended, like you’re trying to call them fat. People don’t want to hear that terminology, they already feel bad anyway. You have to come at it at a different angle.’’ Clinicians also reported linking weight to worsening chronic conditions to get patient’s attention. For example, one clinician said, ‘‘I just let them know that there are ways that we can prevent [them] from having a heart attack and stroke, you know, or prevent kidney disease and dialysis. And when you say dialysis to a diabetic, they understand. They look at you like, ‘Oh Lord, no. I can’t have that,’ because they know what that means.’’
A number of clinicians also reported bringing up weight when talking about decreasing medications. A clinician described telling patients, ‘‘We can decrease your medicine and eventually take you off [of it] if you were to eat better and exercise,’’ noting that most patients don’t want to take more medicine or start insulin. Some clinicians also reported that patients bring up weight on their own, making it easier to talk about it: ‘‘A lot of times the patient brings it [weight] up herself or himself saying that, ‘I need to do something about this weight.’ And, if they bring it up, that’s great because I can give them guidelines on it.’’ While a majority of clinicians reported being sensitive about when and how they brought up weight with obese patients, a few clinicians reported being direct and to the point about it. For example, one clinician said, ‘‘I’ll just usually say straightforward, ‘You need to lose some weight,’’’ while another said, ‘‘I think [we] are socially too sensitive about weight. I like to bring it from a little bit harsher standpoint.’’ The few clinicians who reported taking this approach tended to be physicians and tended to be male. They also described an awareness that this direct approach did not necessarily yield positive patient reactions. For example, one clinician said, ‘‘I’m not everybody’s cup of tea. I believe in honesty. I believe in helping you to identify what the issues are when it comes to your health. And then saying to you this is where we are. . .Unfortunately, not everybody wants to talk about [that].’’ 3.4. What do clinicians say to patients about their weight? All clinicians reported offering patients dietary advice and/or advice about physical activity, and a few reported advising patients about specific weight loss goals. 3.4.1. Dietary advice Clinicians reported providing a wide variety of dietary advice to patients, with the majority reporting they advise patients to avoid or add certain food to their diet. Clinicians talked about asking patients to avoid soda or sugar-sweetened beverages, fried foods, and processed foods. For example, one clinician described asking patients about soda consumption by saying, ‘‘How many sodas are you having a day? Well, you know what, let’s cut that down and have one less each day.’’ Another clinician described asking them to avoid processed foods: ‘‘I ask them to try to avoid processed food and then we talk about what processed foods mean – it’s the stuff in boxes, stuff with a long shelf life, has a lot of chemicals in it. And I usually tell them to try to think about how their great grandmother might have cooked – fresh fruits, vegetables. . . I always try to tell them to try to avoid the processed things – the longer the shelf life, the shorter you’ll live.’’ Advice about adding foods was not always consistent among clinicians. For example, some clinicians described advising patients to add complex carbohydrates to their meals, while others reported advising patients to limit all carbohydrates to lose weight. Most clinicians reported asking patients to add more fruits and vegetables to their diet. Often clinicians talked about advising patients to avoid one type of food while adding another, for example, ‘‘I tell them, ‘I want you to avoid sugar as much as possible, try to eat more complex carbohydrates.’ And I explain what a complex carbohydrate is, like ‘eat brown foods, nothing white’.’’ In addition to adding or avoiding certain foods, some clinicians also talked about advising patients to drink more water, eat breakfast, prepare foods at home (vs. buying prepared food), or eat smaller meals. Lastly, many clinicians reported advising patients to following a specific diet or dietary approach (e.g., low carb, low sugar, low fat), though these approaches differed widely among clinicians.
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3.4.2. Advice about physical activity Clinicians were less likely to describe detailed advice given to patients about physical activity. While physical activity was mentioned in almost every interview, it was typically general (e.g., ‘‘I tell them to get some physical activity.’’). When probing about physical activity advice, some barriers emerged, including that patients were often too obese to exercise, or did not have access to gyms or physical activity equipment. Walking was the most common physical activity strategy addressed. A few clinicians specified that they work with individuals to set small physical activity goals and increase them over time or even demonstrate exercises in their office. 3.4.3. Advice specifically about weight loss Only a few clinicians reported talking to patients about losing a specific amount of weight. In these cases, some clinicians said they provide patients with an overall weight goal, and some clinicians reported breaking up the higher weight goal into smaller increments or suggesting their patient focus on trying to lose ‘‘one to two pounds per week.’’ 3.5. What treatment resources do clinicians offer patients for weight loss? An overwhelming majority of clinicians interviewed reported that they did not have any external behavioral treatment resources (e.g., dietician, class, program) to offer patients who wanted to or needed to lose weight, either because resources were not available in their area, or because resources were too costly for patients to be able to access. Only two clinicians reported that they had available and reliable local resources for patients. Both of these clinicians practiced in a more metropolitan area. If clinicians had resources, most seemed to be for people with diabetes. If these were the only resources available to patients, some clinicians reported using them for those without diabetes too, ‘‘We don’t have a lot of resources to refer people to. Here, we have a diabetic education class that focuses on all aspects of diabetes and a lot of nutritional aspects; that meets every two months. I refer the patients to that even if they’re not a diabetic.’’ In the absence of available resources, clinicians develop or use existing brochures or handouts, refer patients to in-house weight programs, or use online resources. Brochures or handouts seemed to be the most common treatment resource, however the subject matter and type of handouts seemed to vary widely. While some handouts described were from established organizations (e.g., the American Diabetes Association, the Food and Drug Administration), others were created by the clinicians based on their own research and knowledge. For example, one clinician said, ‘‘I came up with my own little list of things that [patients] can use to make small changes, and I hand it to them [during the visit]. It’s a list of 15 things.’’ Clinicians also reported sending patients to online resources. These varied widely and included suggesting patients conduct a Google search; sending patients to websites with calorie counting apps and recipes; and sending patients to federal and commercial websites like choosemyplate.gov, the Biggest Loser website, or the Forks Over Knives website. Only a few clinicians reported having in-house weight loss programs. In all cases, they were developed by a physician at the clinic who had a particular interest in weight counseling. In most cases, the programs were also linked to ongoing monitoring or weight loss medications. While most clinicians said patients routinely ask for medications or other ‘‘quick fix’’ solutions, only a small number were willing to prescribe and monitor weight loss medication. Similarly, only a few clinicians reported referring obese patients for surgery.
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3.6. Basing advice and treatment on personal experience Many clinicians said the advice and treatment they offered patients was based on their own experience with weight. For example, when talking about advising patients to buy healthy foods, one clinician said, ‘‘I tell them my own experience, I’m like, ‘Listen, when I go in the grocery store, I want to go down that cookie aisle too. But I don’t do it because I know if I bring it home, I’m going to eat all of it.’ I make it kind of personal.’’ When talking about exercise, another clinician said, ‘‘I hate treadmills, stationary bikes, and exercise machines because all I do is watch the clock and see how far I go. It’s easier to say, ‘I need to do 5 more [minutes] than the 5 I already did’ than to say, ‘I need to stay on this for 30 minutes’. I approach my own life that way, in bite size pieces, and it works for me. So I just feel like it would work for my patients.’’ Both clinicians who reported having successfully lost weight, and those who had not, used this strategy. Clinicians seemed to agree that sharing their own experience would help build rapport with patients. For example, one clinician said: ‘‘I have a unique approach, because I, myself, went through weight loss a couple years ago. I managed to lose 45–50 pounds through exercise and through eating right and counting calories. So I know how difficult it is to lose weight, I know how difficult it is to change how you eat, I know how difficult it is to get up and exercise for an hour every single day. And so I feel like I have a connection with individuals that really want to lose weight.’’ Another clinician said, ‘‘Well I do not have an optimal BMI myself, so I usually say, ‘well it looks like 100% of the people in this room need to work on their diet and exercise some more.’ And because I know that the patients have been to other doctors who usually look down their nose and tell them they need to lose weight and those doctors are usually the ones with BMI’s of 23, I try my best to sympathize with the patient.’’ 4. Discussion and conclusion 4.1. Discussion This study is among the first to elicit qualitative information from primary care clinicians in CHCs about how they approach weight loss counseling with adult patients; prior qualitative studies in this area have included CHCs, but have not exclusively focused on the CHC setting [18]. Important findings from this study include the reported lack of available or accessible weight-related treatment or referral resources for adult patients, including a lack of internal clinic-based resources like nutritionists and health coaches, or low-cost external resources like weight loss programs or exercise programs that could provide more intensive behavioral treatment. In the absence of these resources, clinicians provide patients with varied advice and treatment, much of which is based on their own experiences or personal knowledge rather than evidence-based practice. More research is needed to assess why evidence-based treatment approaches are not used in the absence of available and credible external referral resources. It may be that clinicians lack adequate time and training to provide patients with evidencebased dietary, physical activity, and weight loss approaches. Still, it is promising that clinicians in this study reported regularly addressing weight in the absence of treatment resources; other studies have found that clinicians base their decision to address weight on whether or not weight-loss programs exist for patients in the community [18]. No other study that we are aware of has found that clinicians use their own experience with weight when counseling patients. Future studies should seek to assess how common this approach is, and whether or not it makes patients more receptive to discussions about weight.
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Findings suggest some common approaches that were shared by most clinicians. For example, a majority of clinicians we interviewed reported addressing weight with established patients with whom they had rapport or with patients who had weight-related chronic diseases. These findings are consistent with research that suggests that clinicians may determine whether or not to address weight with obese patients based on their own perceptions about the success of the intervention, the availability of treatment resources, the patient’s receptivity to the counseling, and the presence of a teachable moment like a weightrelated disease [18]. Clinicians also reported addressing weight in the context of related chronic disease. A previous study found that weight-related chronic conditions offer a teachable moment to address weight-related behaviors [18]. These data suggest that clinicians offer patients specific advice about dietary changes they can make. This finding is contrary to previous data suggesting that weight loss counseling often lacks the provision of specific changes patients could make to diet [29]. However, these data suggest that specific advice about physical activity was rarely provided. This may be because patients were perceived to be uninterested in or unable to be physically active. More research is needed to determine possible barriers clinicians face in the provision of advice about physical activity. 4.2. Implications for practice These data have important implications for practice. First, evidence-based treatment approaches may need to be detailed or adapted to meet the needs of the over-burdened primary care clinician. More research is needed to identify appropriate interventions that can be used in CHCs; a majority of the evidence-base in obesity counseling and treatment comes from other practice settings. Second, identifying new clinical team members, such as health coaches or dieticians, and training them to provide more intensive weight counseling to patients could support primary care clinicians. However, if the use of ancillary care providers is recommended, clinics may need financial support and incentives to be able to staff these individuals. These positions could be created and reimbursed as part of the patient centered medical home (PCMH). Effective weight management and physical activity counseling should be incentivized as important quality measures for a PCMH. Third, findings suggest that community-clinic linkages have not been created consistently in CHCs; public health efforts should focus on working with communities and clinics to create easy access (both for patients and for clinicians) to evidence-based referral resources [16], and on identifying appropriate incentives to motivate patients to use identified resources. Finally, electronic health records could also be leveraged to provide clinicians with decision support prompts, facilitating more evidence-based interactions in the clinic. 4.3. Limitations The following limitations should be considered when interpreting results from this study. First, these findings are from clinicians at CHCs in the southeastern U.S. It is unclear whether similar themes exist among clinicians practicing in other regions of the country. Second, these data are qualitative, and cannot be used to make broad inferences about the beliefs or behaviors of a larger clinician population. Rather these findings suggest possible behavioral and contextual reasons why clinicians may address weight inconsistently with patients. Third, our findings are based on self-reports from clinicians and do not include direct observation or discussions with patients.
4.4. Conclusion Findings suggest that clinicians at CHCs in Georgia are using a variety of approaches to address weight, but lack sufficient tools, staff, and resources to support their efforts. Increased availability of evidence-based referral resources, use of decision support tools, and clinical team training could be used improve weight counseling in CHCs. Funding The qualitative study described in this manuscript was funded by Cooperative Agreement Number 1U48DP0010909-01-1 from the Centers for Disease Control and Prevention and the National Cancer Institute. The contents of this article are solely the responsibility of the authors and do not necessarily represent the official views of the CDC or NCI. Conflict of interest The authors do not have any conflicts of interest to report.
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