Physician weight loss advice and patient weight loss behavior change ...

International Journal of Obesity (2013) 37, 118 - 128 & 2013 Macmillan Publishers Limited All rights reserved 0307-0565/13 www.nature.com/ijo

REVIEW

Physician weight loss advice and patient weight loss behavior change: a literature review and meta-analysis of survey data SA Rose1,2, PS Poynter1, JW Anderson1, SM Noar3 and J Conigliaro4 Primary care providers (PCPs) can empower their patients to make health-promoting behavior changes. Many guidelines recommend that PCPs counsel overweight and obese patients about weight loss, yet few studies examine the impact of provider weight loss counseling on actual changes in patient behavior. We performed a systematic review and meta-analysis of published studies of survey data examining provider weight loss counseling and its association with changes in patient weight loss behavior. We reviewed the published literature using keywords related to weight loss advice. We used meta-analytic techniques to compute and aggregate effect sizes for the meta-analysis. We also tested variables that had the potential to moderate the responses. A total of 32 studies met criteria for the literature review. Of these, 12 were appropriate for the meta-analysis. Most studies demonstrated a positive effect of provider weight loss advice on patient weight loss behavior. In random effects meta-analysis, the overall mean weighted effect size for patient weight loss efforts was odds ratio (OR) ¼ 3.85 (95% confidence interval (CI) 2.71, 5.49; Po0.01), indicating a statistically significant impact of weight loss advice. There was no significant difference in the effectiveness of advice in studies using obese patients alone versus mixed samples (obese alone OR ¼ 3.44, 95% CI 2.37, 5.00; mixed sample OR ¼ 3.98, 95% CI 2.53, 6.26, P ¼ 0.63). PCP advice on weight loss appears to have a significant impact on patient attempts to change behaviors related to their weight. Providers should address weight loss with their overweight and obese patients. International Journal of Obesity (2013) 37, 118--128; doi:10.1038/ijo.2012.24; published online 27 March 2012 Keywords: physician; counseling; documentation; patient behavior; meta-analysis

INTRODUCTION Obesity is a major clinical and public health problem associated with an increased risk of morbidity and mortality and is related to many comorbidities treated by primary care providers (PCPs).1,2 Intentional weight loss can potentially mitigate this increased risk.3,4 Studies on tobacco and alcohol use counseling in the clinical setting demonstrate that physicians can have a positive impact on changing patient behaviors, even with brief counseling.5,6 Advocating similar methods, multiple organizations recommend physician screening and counseling for overweight and obesity, but most physicians do not appear to be advising their patients to lose weight.7 - 12 Lack of physician counseling may be related to controversy regarding the effectiveness and realistic nature of weight counseling. The United States Preventive Services Task Force (USPSTF) found good evidence to recommend that clinicians screen all patients for obesity through measurement of body mass index. However, they found fair to good evidence that only ‘highintensity counseling and behavioral interventions’, defined as more than one person-to-person session during at least the first 3 months, were effective for treatment purposes, and that evidence for less-intensive interventions that may be more feasible in the clinical setting was insufficient.8 The few studies that address health care provider self-efficacy on the topic of weight find that providers face challenges with weight counseling, including a lack of tools, training, reimbursement, staffing and time, and relay a lack of confidence in their own abilities and in the effectiveness of weight loss strategies in general.10,13 - 17

The purpose of this study was to examine whether PCP counseling enhances patient engagement in weight reduction efforts. We aimed to systematically review the survey literature regarding the effectiveness of PCP-provided advice related to patient weight loss behaviors, followed by a meta-analysis examining the hypothesis that PCP counseling would enhance patient participation in weight loss efforts.

MATERIALS AND METHODS Literature review search strategy We performed an extensive search related to the effect of provider weight loss advice on patient behavior. We conducted a review of published literature in the English language using numerous keywords in combination relating weight loss advice, including physician, counseling, overweight, obese, weight loss, advice, diagnosis, documentation, recording, recognition, screening and cardiovascular risk. We performed searches in PubMed, Web of Science, PsycINFO, Cochrane Library, ERIC, Dissertation and Theses and WorldCat, and used PubMed MeSH headings and analogous search strategies in other databases. No limitations were made upfront; however, one relevant non-English language article was excluded from the coding. Searches included articles published through November of 2011. An initial search using PubMed alone found five articles with the outcome appropriate for inclusion in the meta-analysis,18 - 22 with one later removed in favor of an article using the same data set with a larger, more generalizable population.21 The list of references for each of these articles was searched for additional potential articles.

1 University of Kentucky College of Medicine, Department of General Internal Medicine and Geriatrics, Lexington, KY, USA; 2University of Kentucky College of Public Health, Department of Epidemiology, Lexington, KY, USA; 3University of North Carolina at Chapel Hill School of Journalism and Mass Communication, Chapel Hill, NC, USA and 4New York University School of Medicine, Department of Medicine, New York, NY, USA. Correspondence: Dr SA Rose, University of Kentucky College of Medicine, Department of General Internal Medicine and Geriatrics, 740 South Limestone, K507, Lexington, KY 40536-0284, USA. E-mail: [email protected] Received 18 August 2011; revised 17 January 2012; accepted 21 January 2012; published online 27 March 2012

Physician weight loss advice and patient change SA Rose et al Inclusion criteria included all of the following: patient impression of the efficacy of PCP weight loss advice or counseling on overweight status as noted through survey or observational study data; evaluation of the discussion of overweight status between a patient and his/her provider during an office visit; inclusion of patients of all weights, provision or selfreported or chart-documented information about physician advice and weight history; and written in English. Because many studies did not specify, studies involving any PCP, such as a physician, nurse practitioner or physician assistant, were included in this review, and we use the terms primary care provider or provider to mean any of these practitioners.

Article coding We used the Preferred Reporting Items for Systematic Reviews and MetaAnalyses (PRISMA) criteria for reporting our meta-analysis.23 Articles were coded on multiple dimensions by two coders including demographics such as age; clinical characteristics such as body mass index; survey characteristics such as method of survey participation (telephone, in-person or written), deliverer of weight loss advice (attending physician, resident physician or other provider), type of practice (internal medicine, family practice, pediatrics, other) and survey type and year, and methodological characteristics including type of counseling received regarding weight loss and type of counseling received regarding physical activity or dietary change or decreasing comorbidities. Because some of the articles presented outcomes in adjusted form, we coded for adjustment. Satisfactory intercoder reliability was established with an average percent agreement across all categories of 86% (k ¼ 0.75), with coding differences resolved through discussion. To assess study quality, we used a standardized abstraction form by Zaza et al.,24 the purpose of which is to assess the quality of the study across six categories, including intervention and study descriptions, sampling, measurement, analysis, interpretation of results and other execution issues. Two coders calculated the quality of each article on each category, and differences were resolved through discussion.

Effect size extraction and calculation The odds ratio (OR), or the odds of an event occurring in an exposed population divided by the odds of an event occurring in an unexposed population, was used as the effect size indicator. We calculated effect sizes from data from each article using appropriate formulas. The primary exposure was provider weight loss advice, and the primary outcome was patient weight loss attempt. We used meta-analytic techniques to compute and aggregate effect sizes for the 12 studies that met inclusion criteria. We also carried out sensitivity analysis on variables believed to have the most potential to moderate the responses.

Meta-analytic approach We used Microsoft Excel to calculate totals, means and medians for our demographic and clinical characteristics. We used the Comprehensive Meta-Analysis software program, version 2.0 (Comprehensive Meta-Analysis, Englewood, NJ, USA), to calculate effect sizes and weight them by sample size. We combined the effect sizes using standard random effects meta-analytic procedures and presented them with their 95% confidence intervals (CIs). We used the Q statistic and the I2 statistic to look for significant heterogeneity among the effect sizes. In testing categorical variables that had the potential to moderate the responses, we calculated them along with their 95% CIs, and compared them with one another using the Qb and I2 statistics.25 Attempts were made to contact authors when additional raw data were needed.

RESULTS We found 6041 nonduplicate articles for possible inclusion (Figure 1). A number of these articles had low relevancy to the study, whereas many were background information about the evolution of the obesity issue and guidelines or editorials regarding recommendations for provider counseling and & 2013 Macmillan Publishers Limited

treatment. There were also hundreds of articles dealing with interventions that went beyond provider advice. A total of 32 studies were appropriate for the literature review.18 - 22,26 - 52 Of these, 22 had the outcome appropriate for the meta-analysis. Of these 22, 10 were excluded for two reasons. One was use of a similar data set and time point (Behavioral Risk Factor Surveillance Survey (BRFSS); n ¼ 11 of 22, or National Health and Nutrition Examination Survey (NHANES; n ¼ 4 of 22)). Of those from the same year, we used studies with a larger n and a more generalizable population. The other reason was inappropriate reporting of outcomes (n ¼ 2) for calculation in the meta-analysis. In the literature review we included all studies that met inclusion criteria in order to demonstrate the wealth of papers published on this topic, as well as the consistency of findings through different time points and populations. In all, 12 studies were appropriate for meta-analysis. Our literature review assesses the effectiveness of PCP-provided advice related to six different patient weight loss behaviors, and our meta-analysis examines the correlation between PCP counseling and weight loss efforts. Literature review The literature review identified 32 reports with analyzable data18 - 22,26 - 52 related to PCP advice regarding patient overweight and changes in behavior compared with patients not receiving advice. These reports summarized advice from providers regarding weight loss, including the following exposures: (1) advice to lose weight by a provider; (2) specific PCP advice related to weight loss; (3) information or communication from the PCP regarding overweight; (4) and provider use of motivational interviewing to promote weight loss (Table 1). The major outcome focused on increased patient action toward weight loss, and specifically included: (1) patient engagement in weight loss efforts; (2) patient perception of weight loss advice, including perceived success of provider weight loss advice, patient desire for weight loss, and patient confidence in ability to lose weight; (3) patient stages of change, either for readiness to lose weight or for readiness to change weight-related behavior; (4) patient weight maintenance attempt; (5) patient attempt at a specific behavior change related to weight loss; and (6) actual patient weight loss (Table 1). Several studies contained more than one outcome. (1) Patient engagement in weight loss efforts (Table 1, category 1) In all, 22 studies looked for an association between weight loss advice and patient engagement in weight loss efforts (Table 1). Of the 22 studies, 11 used data from the BRFSS, 4 used NHANES data, 1 used National Health Interview Survey (NHIS) data and 6 used local study data (Table 1). Only one did not find a positive association.29 The BRFSS is a standardized, nationwide telephone survey of adults X18 years of age to which states can attach separate modules asking questions focusing on specific comorbidities. These studies focused on questions regarding weight management. A few studies evaluated subsets of the general US population, such as patients with comorbidities, veterans, specific states or certain races and ethnicities. All demonstrated a positive association between PCP weight loss advice and patient weight loss efforts (Table 1). NHANES is an annual national survey that assesses the health and nutritional status of children and adults in the United States through in-person interviews and physical examinations.53 All four studies20,26,45,47 using these data found positive associations between advice and weight loss efforts (Table 1). (2) Patient perceptions of weight loss advice (Table 1, category 2) Eight studies evaluated the association between physician advice and positive thoughts about weight loss by patients (Table 1). Six studies26,28,26,34,35,45,51 found some positive association between International Journal of Obesity (2013) 118 - 128

119

Physician weight loss advice and patient change SA Rose et al

120 Records after duplicates removed (n = 6041)

Records screened (n = 464)

Records excluded (n = 372)

Full-text articles assessed for eligibility (n = 87)

Abstract published as complete study (n=1) Study re-reviewed and found appropriate for literature review (n=1)

Studies included in qualitative synthesis (n = 32)

• Inappropriate study type (n = 24) • No link given between physician recognition and patient outcome (n=13) • Advice provided for specific comorbidity (n=5) • No information on comparison group (n=3) • Abstract only (n=3) • Foreign language (n=1) • Thesis (n=4) • Link between advice and outcome inappropriate for study (n=1) • Inappropriately presented outcomes (n=1) • Commentary (n=2)

Studies included in quantitative synthesis (meta-analysis) (n = 12 )

Figure 1.

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram of article search strategy.23

PCP discussion of weight and patient confidence in the ability or desire to lose weight (Table 1). (3) Patient stage of change (Table 1, category 3) Four studies evaluated physician advice and patient stage of change, based on Prochaska’s transtheoretical model of the five stages of change, which includes precontemplation, contemplation, preparation, action and maintenance (Table 1). This model can be used to determine a patient’s receptiveness to specific strategies or actions. Despite differences in patient population and definition of positive stage of change, all but one52 found a positive association between physician advice and increased stage of readiness for weight loss (Table 1). (4) Patient weight maintenance attempt (Table 1, category 4) All three studies assessing the correlation between PCP counseling on weight loss or about overweight and weight loss maintenance found a positive correlation between the two.20,27,47 Patient attempt at a specific behavior change related to weight loss (Table 1, category 5) (5) Patient attempt at a specific behavior change related to weight loss (Table 1, category 5). In all, 11 studies examined the association between provider weight loss advice and attempts by patients at International Journal of Obesity (2013) 118 -- 128

specific behavior changes related to weight. Of these 11, 8 studies29,34,38,40,41,48,50,51 found a positive association between physician weight loss advice and dietary change. All studies, except those of Himmel et al.38 and Rodondi et al.,39 examined the association between weight loss advice and physical activity, but only three found a positive association.28,48,51 Rodondi et al.39 found a positive association between physician weight loss advice and seeing a dietitian and setting a target weight, but not between advice and reading self-help material to lose weight (Table 1). (6) Actual weight loss by a patient (Table 1, category 6) A total of seven studies examined actual patient weight loss and its association to provider advice, and all found some positive associations between the two (Table 1). Singh et al.26 used NHANES data and found a positive association between physician diagnosis of being overweight and intentional weight loss of X5% (prevalence ratio 1.87; 95% CI 1.61, 2.17). Singh et al.47 used the same data set but looked specifically at patients with cardiovascular disease and central obesity, and found a positive association between patient report of PCP recognition of overweight and intentional weight loss of X5% (OR 2.78, 95% CI 1.37, 5.63). Himmel et al.38 surveyed overweight patients from a solo physician family practice in Northern Germany. Of those & 2013 Macmillan Publishers Limited

BRFSS 1994, 1996, 1998, 2000

BRFSS 2000 and 2005

BRFSS 2000

BRFSS 2000

Local written pt questionnaires 2006 Local written survey 2005

NHANES 2005 - 2008

Felix et al.31

Fontaine et al.32 Ford et al.42

Wang et al.33

Thande et al.22 Zapka et al.44

Post et al.45

Kabeer et al.34

Pollak et al.28

1

1

& 2013 Macmillan Publishers Limited

1

1

1, 2

1, 2, 5

1, 2, 5

Nawaz et al.27 Kant and Miner20

1, 4

1, 4, 5

1, 3

Singh and LopezJimenez26 Huang et al.19

1, 2, 6

1

1

1

1

NHANES 1999 - 2000 and 2001 2002

BRFSS 1994

Oral exit interview September 2001 - January 2002

NHANES 1999 - 2004

Local and pre- and post-office visit Telephone survey and inperson oral survey at the time of the office visit

BRFSS and CVD-TI 1996

BRFSS 2005

BRFSS 2000

BRFSS 1996

Galuska et al.18 Mehotra et al.21 Abid et al.30

1

Survey type

Study (author) and publication year (Ref no.)

US OW teenagers (16 - 19 years of age), n ¼ 716

US OW adults, n ¼ 320



US OW and OB female adults, n ¼ 25

US OW and OB adults in Missouri, n ¼ 3101

US OW and OB adults, n ¼ 5474

Assessment of association between physician advice about OW and pt WL attempt Evaluation of PCP and pt perception of WL counseling, pt perception of PCP WL recommendations and current pt WL activities Assessment of WL counseling and WL attempt and maintenance Assessment of professional counseling about OW, WL attempt and specific subject dietary and PA barriers

Examination of association of MI techniques with pt WL attempts

Correlation between PCP recognition of pt OW and pt WL attempt and behavior change related to weight loss Assessment of association between PCP WL advice and pt WL attempt

Assessment of PCP WL counseling practices Evaluation of pt wt, wt perception and participation in WL practices

Comparison of WL attempts with and without WL advice Comparison of WL attempts with and without WL advice Assessment of an association between WL advice and WL attempt using BRFSS 2000 Comparison of BRFSS 2000 and 2005 data regarding WL counseling and pt WL attempt Assessment of PCP counseling on WL to control arthritis sxs in OB pts Assessment of PCP counseling on WL to control asthma morbidity Assessment of association between PCP wt control advice and pt WL attempt

US OB adults, n ¼ 12 835 US OB adults with arthritis, n ¼ 7969 US OB adults, n ¼ 24 179 (year 2000) US OB adults, 2000 n ¼ 5525 and 2005 n ¼ 11 569 US OW and OB adults with arthritis, n ¼ 10 144 US Adults of all wts with asthma, n ¼ 10 955 US OW and OB adults, n ¼ 178 735 non-VA users n ¼ 3391 VA users US adults of all wt categories, n ¼ 256 US OW and OB adults, n ¼ 813

Study description

Sample, n

Studies included in literature review and meta-analysis

Outcome category no.

Table 1.

3

1

1, 2

1

4

1

3

1

1

1

1

1

1

1

1

1

Exposure(s)

(1) (4) (1) (4) (5) (5)

89% vs 52% (P ¼ 0.001) WL or wt maintenance attempt: 95% vs 81% (P ¼ 0.002) OR 2.7 (1.7, 4.4) OR 2.3 (1.5, 3.6) attempt at dietary change: OR 1.9 (0.9, 4.3) attempt at physical activity: OR 1.2 (0.5, 2.8)

(1) 78% vs 32% (OR 4.6; 2.8, 7.5) (2) desire to lose wt: 98% vs 59% (OR 26.9; 7.6, 95.3) (5) attempt at dietary change: 91% vs 89% (OR 1.7; 2.8, 7.5) (5) attempt at PA: 65% vs 75% (OR 0.9; 0.5, 1.6) (1) Significantly correlated with MI adherent behavior (Spearman association ¼ 0.42) (2) Confidence in losing wt: no significant association (2) Readiness to lose wt: significantly correlated with wt discussion (0.52), time spent on wt (0.42) and MI spirit (0.63) (5) Attempt at dietary change: no significant association (5) Change in exercise programs: significantly correlated with empathy (0.50) and MI spirit (0.47) (1) PrR 1.49 (1.61, 2.17) (2) Desire to weigh less: PrR 1.28 (1.25, 1.31) (6) intentional weight change of X5%: PrR 1.87 (1.61, 2.17) (1) OR 7.25 (3.05, 17.21) (3) increased readiness for WL: 91% vs 64% P ¼ 0.001

(1) Stratified by race/ethnicity White OR 1.18 (1.03, 1.35) Black OR 2.72 (1.52, 4.84) (1) OR 2.84 (2.55, 3.18) (2) Desire to weigh less: 97.4% vs 86.1% (Po0.001)

(1) OR 18.03 (6.63, 49.04)

(1) 80% vs 59%

(1) 82.9% vs 63.8% (Po0.001) (OB pts only)

(1) OR 3.75 (3.39, 4.15)

(1) OR 2000: 2.9 (2.4, 3.6); OR 2005: 3.9 (3.2, 4.7)

(1) OR 2.8 (2.5, 3.2)

(1) 80.5% vs 48.9% (adjusted OR 2.8, 2.5, 3.1)

(1) 79% vs 57.6% (OR 2.79, 2.53, 3.08)

Outcome no. (and specific action if applicable), percentage and P-value or OR (95% CI) for pts receiving PCP advice vs not


121

International Journal of Obesity (2013) 118 - 128

International Journal of Obesity (2013) 118 -- 128

BRFSS 2000

Bish et al.41

Dorsey and Songer48

Sciamanna et al.40

Saelens et al.29

1, 5

1, 5

1, 5

1, 5

Local written survey

Evans35

Jay et al.

2

2

Local in-person survey

Local written survey

Himmel et al.38

Local written questionnaires

BRFSS 1996

1, 5, 6

49

NHANES 1999 - 2004

Singh et al.47

1, 4, 6

NHIS 2006

Survey type



Table 1 (Continued )

UK OB adult pts who had lost at least 45 kg, n ¼ 372 US OB adult pts, n ¼ 137

Germany OW and OB adults, n ¼ 740

US normal, OW and OB adolescents (12 - 18 years), n ¼ 110

US adults of all wt categories, n ¼ 10 187

US OW and OB adults, N ¼ 2005 (n ¼ 563 with prediabetes and n ¼ 1442 with diabetes)

US OW adults with cardiovascular disease and central obesity, n ¼ 907 US adults of all wts, n ¼ 164 187

Sample, n

Evaluation of success of doctor WL advice in encouraging pts to lose wt Correlation between quality of physician WL counseling and pt motivation for WL and

Assessment of recognition, counseling and treatment of OW from PCP and pt viewpoint

Search for association between PCP wtrelated counseling and adolescent wt control efforts

Assessment of association between PCP advice and pt WL attempt

Comparison of WL attempts with and without WL advice

Comparison of WL attempts with and without WL advice

Correlation between PCP recognition of pt OW and pt WL attempt, weight maintenance and actual WL

Study description

1, 2

1

2, 3

2

1

1, 2

1

1

Exposure(s)

(1) Women OR 6.24 (5.5, 7.09) Men OR 10.13 (8.53, 12.03) (5) attempt at dietary change: Women OR 1.25 (1.15, 1.37) Men OR 1.25 (1.11, 1.41) (5) attempt at PA: Women OR 0.94 (0.86, 1.04) Men OR 0.92 (0.81, 1.04) (1) Prediabetes men ¼ not calc Prediabetes women ¼ not calc Diabetes men ¼ 9.1 (5.4, 15.4) Diabetes women ¼ 4.1 (2.5, 6.6) (5) Dietary change: Prediabetes men ¼ 1.7 (0.8, 3.9) Prediabetes women ¼ 2.8 (1.5, 5.3) Diabetes men ¼ 11.3 (6.7, 19.0) Diabetes women ¼ 5.7 (3.7, 8.6) Physical activity increase: Prediabetes men ¼ 3.6 (1.5, 8.7) Prediabetes women ¼ 3.0 (1.5, 5.9) Diabetes men ¼ 4.6 (2.9, 7.4) Diabetes women ¼ 2.8 (1.8, 4.4) (1) Po0.001 (5) attempt at dietary change: 61% vs 48%, Po0.01 (BMI 25 - 27 kg m - 2) (5) attempt at PA: not significant for any wt category (1) P ¼ 0.28 (5) eating less food/fewer snacks: 86% vs 71% (5) eating more fruits/vegetables: 86% vs 80% (5) getting more exercise: 87% vs 89% (5) eating foods lower in fat: 83% vs 85% (5) counting calories/write down foods: 83% vs 55% (5) taking medication/diet pills: 67% vs 17% (5) skipping meals: 100% vs 55% (5) vomiting/purging: NA% vs 100% (1) 40% tried to lose weight who ranked advice as good, compared with 8% who ranked it as average or poor (5) dietary treatment: 54% tried to change their diet who ranked advice as good, compared with 42% who ranked it as average, and 4% who ranked it as poor (6) 28% reported actual WL of 43 kg who ranked advice as good, compared with 50% who ranked it as average, and 12% who ranked it as poor (2) Advice reported to be successful: 6%; Reported to be indirectly effective: 23% (2) OR 0.770 (0.204, 2.902)

(1) OR 2.31 (1.33, 4.00) (4) OR 2.49 (1.72, 3.62) (6) intentional WL of X5%: OR 2.78 (1.37, 5.63)



122



Local in-person survey (Project CHAT-- Communicating Health-Analyzing Talk)

Cox et al.50

Alexander et al.51

Fallon et al.36

2, 5

2, 5, 6

3


Levy and Williamson43

6

Telephone survey 1980 - 1981

Rondoni et al.39

5, 6

US adult pts of all wt categories, n ¼ 365 Switzerland OW and OB adults, n ¼ 523

Local telephone survey November 2001 - June 2009

Wee et al.37

3

US OB adult pts, N ¼ 152

US adults of all wts, n ¼ 572



Sample, n

Local in-person interview and written questionnaire emailed to home at 1 year

Local in-person survey

Jay et al.52

3

Local telephone survey 2002

Local in-person survey (Project CHAT-- Communicating Health-- Analyzing Talk)

Survey type




Determination of factors related to WL and considered important by those who had lost wt

Evaluation of a association between PCP motivation of pts and pt improvement in WL, diet, and exercise Evaluation of PCP counseling of OW and OB pts during clinic visits and effect on pt wt and wt control efforts 1 year post visit

Correlation between PCP use of 5A’s and advanced obesity counseling practices and pt stage of change

Evaluation of rate and correlates of physician WL advice and of the association between advice and pt stage of change

Correlation between PCP use of 5A’s counseling techniques and pt confidence to lose weight, pt dietary and PA change and actual pt WL

Correlation between PCP counseling techniques and pt motivation and confidence to change WL behaviors

Study description

3

1, 2

2

1, 2

1, 2, 3

4

Exposure(s)

(5) Setting a target wt: 56% vs 36% (Po0.001) (5) modifying diet to lose wt: 47% vs 38%, P ¼ 0.09 (5) visiting a dietitian: 23% vs 10%, P ¼ 0.001 (5) reading self-help material: 24% vs 34%, P ¼ 0.09 5) X1 pt behavior to control wt: 82% vs 62% Po0.001 (6) mean wt change: 1 kg (s.d. 5.0) vs +0.3 (s.d. 5.0) P ¼ 0.02 (6) P ¼ 0.01

(2) Motivation PCP MI consistent behavior OR 0.8 (0.3, 1.8) PCP MI spirit OR 0.9 (0.4, 2.0) Confidence PCP MI consistent behavior OR 1.9 (0.8, 4.4) PCP MI spirit OR 0.8 (0.3, 1.8) (5) Nutrition Motivation PCP MI consistent behavior OR 1.0 (0.4, 2.6) PCP MI spirit OR 0.8 (0.3, 1.9) Confidence PCP MI consistent behavior OR 2.6 (1.2, 5.7) PCP MI spirit OR 0.6 (0.3, 1.5) Exercise Motivation PCP MI consistent behavior OR 0.9 (0.4, 2.1) PCP MI spirit OR 1.2 (0.5, 2.5) Confidence PCP MI consistent behavior OR 1.8 (0.8, 4.0) PCP MI spirit OR 0.8 (0.3, 1.8) (2) Positive association between patient confidence to lose weight and PCP advise (P ¼ 0.05), and assess (P ¼ 0.05) (5) Change diet: positive association between diet change and PCP assist (P ¼ 0.001), and arrange (P ¼ 0.001) Change PA: no significant association between PCP use of 5A’s and PA change (6) Positive association between patient weight loss and PCP Arrange (P ¼ 0.05) (3) Stage of change for engagement in WL efforts: OR 1.86 (1.13, 3.06) (3) stage of change for moderate to vigorous PA: OR not given (P ¼ 0.07) (3) stage of change for fruit and vegetable consumption: OR 2.25 (1.4, 3.62) No significant relationship found between percent of pts in action of maintenance stage and higher PCP use of 5A’s (s.d. b ¼ 0.11, R2 ¼ 0.1%) or advanced obesity counseling by PCP (s.d. b ¼ 0.09, R2 ¼ 0.3%) (3) Stage of change for readiness to lose wt: 53% vs 36%, Po0.05



123




Abbreviations: 5A’s, Assess, Advise, Agree, Assist and Arrange; BMI, body mass index; BRFSS, Behavioral Risk Factor Surveillance System; 95% CI, 95% confidence interval; CVD-TI, Cardiovascular Disease Targeted Initiative; MI, motivational interviewing; n, number; NHANES, National Health and Nutrition Examination Survey; NHIS, National Health Interview Survey; OB, obese; OR, odds ratio; OW, overweight; PA, physical activity; PCP, primary care provider; PrR, prevalence ratio; pt, patient, Ref, reference; sxs, symptoms; VA, Veterans Administration; WL, weight loss; wt(s), weight(s). Exposures: (1) PCP weight loss advice, either for general health or to improve a specific comorbidity; (2) specific PCP advice related to weight loss; (3) information or communication from the PCP regarding overweight; (4) PCP use of MI to promote weight loss. Outcomes: (1) Patient engagement in weight loss efforts; (2) patient perception of weight loss advice, including perceived success of provider weight loss advice, patient desire for weight loss and patient confidence in ability to lose weight; (3) patient stages of change, either for readiness to lose weight or for readiness to change weight-related behavior; (4) patient weight maintenance attempt; (5) patient attempt at a specific behavior change related to weight loss; (6) actual patient weight loss.

(6) WL counseling: +0.1 kg (0.7, 0.8; P ¼ 0.84) MI counseling techniques MI spirit:1.6 kg (2.9, 0.3; P ¼ 0.02) Reflection: 0.9 kg (1.8, 0.1; P ¼ 0.03) Open questions: +0.1 kg (0.8, 0.9; P ¼ 0.86) Empathy: 1.0 kg (2.8, 0.8; P ¼ 0.26 MI consistent behaviors: 1.1 kg (2.3, 0.1; P ¼ 0.07) 1,4 Difference in actual pt WL over 3 months between pts receiving PCP WL counseling and use of MI counseling techniques US OW and OB adults, n ¼ 426 Local in-person survey (Project CHAT-- Communicating Health-Analyzing Talk) Pollak et al.46 6

Sample, n Survey type Study (author) and publication year (Ref no.) Outcome category no.


Study description

Exposure(s)


124

who ranked their communication with their physician as ‘good’, 28% had lost at least 3 kg as compared with 20% who did not rank communication as good. Of those ranking communication as ‘average’, 50% reported weight loss as compared with 55% who did not rank it as average, and 12% ranking communication as ‘poor’ reported losing weight when compared with 25% who did not rank it as poor. Rodondi et al.39 conducted in-person interviews and questionnaires with patients from Swiss universityaffiliated primary care clinics. At the end of 1 year, questionnaire completers (n ¼ 407, 78%) who had received any form of counseling reported an average weight loss of 1 kg as compared with a gain of 0.3 kg (P ¼ 0.002) in those who had not received counseling. After adjustment, counseling with each additional weight loss strategy was associated with a mean weight loss of 0.2 kg (95% CI 0.03, 0.4, P ¼ 0.02). Levy and Williamson43 surveyed 56 obese adult patients from a midwestern university family practice clinic, and found that those who lost weight (n ¼ 21), defined as a loss of at least 2.3 kg over a 5-year period, reported more physician attention to their obesity. Alexander et al.51conducted audio recordings of 40 physicians and 461 of their overweight or obese patients looking for examples of use of the 5A’s (Ask, Advise, Assess, Assist and Arrange) in weight loss counseling, and then conducted a post-visit survey and anthropometric measurement. They found a positive association between 3-month weight loss and physician arrangement for follow-up with physician or nutritionist regarding weight loss (arranged: mean (pre) ¼ 101.4 kg (s.e. 3.49) versus mean (post) ¼ 99.9 kg (s.e. 3.51); did not arrange: mean (pre) ¼ 91.1 kg (s.e. 0.76) versus mean (post) ¼ 91.2 kg (s.e. 0.76), P ¼ 0.05). Pollak et al.46 used the same population as Alexander et al.51 to assess the difference in patient weight loss between patients receiving physician weight loss counseling versus not, and physician use of motivational interviewing techniques. They found a statistically significant weight loss in those patients whose physicians exhibited motivational interviewing spirit (1.6 kg (2.9, 0.3), P ¼ 0.02) and exhibited reflection or understanding of the patient’s statements (0.9 (1.8. 0.1), P ¼ 0.03), but no statistically significant weight change for other physician behaviors. Meta-analysis Study characteristics. The 12 studies included a total of 207 226 individuals, and were published between 1999 and 2011 (Tables 1 and 2). All studies were conducted in the United States. Excluding two articles that did not give demographic information on gender29,31 and one that did not give demographic information on race,31 60% of patients were female and 37% were white. Two studies evaluated a pediatric population.20,29 There were 39 310 (19%) patients who reported receiving advice to lose weight or being told that they were overweight. Two studies18,31 looked only at an obese population, whereas the rest included overweight patients; two studies22,41 included normal-weight patients in their sample. Eight studies used national and four used local survey data. One study did not provide the OR and instead gave a prevalence ratio.26 Satisfactory quality was established with an average percent agreement of 89% across all categories (k ¼ 0.77). Efficacy of intervention: weight loss attempt. All studies except one29 demonstrated a positive effect of PCP advice on patient engagement in weight loss efforts (Figure 2). The overall random effects mean weighted effect size for weight loss efforts including all studies was OR ¼ 3.85 (95% CI 2.71, 5.49; Z ¼ 7.47, Po0.01), indicating a statistically significant impact of weight loss advice on efforts at weight loss. Removal of studies with different populations such as children20,29 and removal of the study with the outlying OR size for the outcome22 did not change the results significantly. & 2013 Macmillan Publishers Limited


320 (25% of total sample) adults from Connecticut

Nationwide sample of 5474 adults

Nawaz et al.27

Post et al.45

813 adult hospital employees from a health care system in central Massachusetts

Zapka et al.44

Overweight and obese adults

Normal-weight, overweight and obese adults

Overweight adults

Overweight adolescents (BMI X85th percentile)


Overweight adults

At-risk for overweight and overweight adolescents (BMI X85th percentile)


Obese adults

In-person

In-person

In-person

In-person

In-person

Telephone

In-person

In-person

Telephone

Telephone

In-person

Telephone

How survey delivered

Local (2005)

BRFSS-based, local (2003)

NHANES, national (1999 - 2004)

Local (2002)

NHANES, national (2005 - 2008)

BRFSS, national (state of Connecticut only) (1994)

NHANES, national (1999 - 2000 and 2001 - 2002)

Local (2001 - 2002)

BRFSS, national (1996)


NHIS, national (2006)


Survey type (year)

White 1.18 (1.03, 1.35) Z ¼ 2.40 P ¼ 0.02 African American 2.72 (1.53, 4.84) Z ¼ 3.40 P ¼ 0.001

18.03 (6.63, 49.04) Z ¼ 5.67 Po0.01

PR ¼ 1.49 (1.42, 1.57) Z ¼ 15.57 Po0.01

1.58 (0.68, 3.70) Z ¼ 1.05 P ¼ 0.29

2.84 (2.55, 3.18) Z ¼ 18.53 Po0.01

7.51 (3.71, 15.21) Z ¼ 5.60 Po0.01

2.34 (1.74, 3.16) Z ¼ 5.56 Po0.01

6.17 (2.70, 14.10) Z ¼ 4.32 Po0.01

2.85 (2.63, 3.09) Z ¼ 25.47 Po0.01

4.17 (3.74, 4.65) Z ¼ 25.70 Po0.01

a

Prediabetes M ¼ not calc Prediabetes F ¼ not calc Diabetes M ¼ 9.1 (5.4, 15.4) Z ¼ 8.26 Po0.01 Diabetes F ¼ 4.1 (2.5, 6.7) Z ¼ 5.70 Po0.01

a

Male ¼ 10.13 (8.53, 12.03) Z ¼ 26.40 Po0.01 Female ¼ 6.24 (5.5, 7.09) Z ¼ 28.26 Po0.01

Effect size (OR, 95% CI)

Abbreviations: BMI, body mass index; BRFSS, Behavioral Risk Factor Surveillance System; CI, confidence interval; F, female; M, male; NHANES, National Health and Nutrition Examination Survey; NHIS, National Health Interview Survey; OR, odds ratio. aNot calculated because of small sample sizes.

256 adult patients from an internal medicine clinic at Columbia University, New York

Nationwide sample of 8767 adults

Thande et al.22

Singh and LopezJimenez26

Saelens et al.

74 adolescents aged 12 -- 18 years from Rhode Island and California

716 teens aged 16 - 19 years from all 50 states

Kant and Miner20

29

210 adults from two primary care clinics affiliated with Louisiana State University

Huang et al.19

Galuska et al.

Nationwide sample of 12 835 adults

Nationwide sample of 11 569 adults

Felix et al.31 Obese adults

Overweight and obese adults with prediabetes and diabetes

Nationwide sample of 2005 adults (n ¼ 563 with prediabetes and n ¼ 1442 with diabetes)

Dorsey and Songer48

18

Normal-weight, overweight and obese adults

164 187 adults from all 50 states, DC, and Puerto Rico

Bish et al.41

Weight categories included

Sample

Characteristics of studies included in the meta-analysis evaluating association between provider advice and patient weight loss attempt

Study (reference no.)

Table 2.


125



126 Study name

Odds ratio and 95% CI

Bish et al. (Male) Bish et al. (Female) Dorsey et al. (Diabetic Male) Dorsey et al. (Diabetic Female) Felix et al. Galuska et al. Huang et al. Kant et al. Nawaz et al. Post et al. Saelens et al. Singh et al. Thande et al. Zapka et al (White) Zapka et al (African-American) Total 0.01

0.1

No provider advice

1

10

100

Provider advice

Figure 2. Odds ratios for the effect of provider advice on patient weight loss attempt for each study and overall in the meta-analysis.

Heterogeneity and intervention moderators. We found significant heterogeneity of the effect sizes among the studies (Q ¼ 1124.09, I2 ¼ 98.76, Po0.01), and therefore looked at between-study moderators that could impact the association of advice and engagement in weight loss efforts. Using random effects analysis, we found no statistically significant difference in the effectiveness of advice in studies using obese patients alone versus mixed samples (OR ¼ 3.44, 95% CI 2.37, 5.00 versus mixed sample OR ¼ 3.98, 95% CI 2.53, 6.26, P ¼ 0.63), studies using national versus local survey data (OR ¼ 4.19, 95% CI 2.75, 6.38 versus 3.33, 95% CI 1.36, 8.15, P ¼ 0.65) or from data published before the 1998 NHLBI (National Heart, Lung, and Blood Institute) guidelines on the identification, evaluation and treatment of overweight and obesity compared with after publication (OR ¼ 4.33, 95% CI 1.69, 11.09 versus 3.81, 95% CI 2.48, 5.85, P ¼ 0.81). We did find a significant difference in patient report of weight loss attempt if advised by their PCP in adults versus children (OR ¼ 4.24, 95% CI 2.90, 6.22 versus 2.24, 1.69, 2.98, P ¼ 0.01), and in patients who were surveyed by telephone compared with in-person survey (OR ¼ 5.50, 95% CI 3.46, 8.72 versus 3.00, 95% CI 2.15, 4.17, P ¼ 0.04). DISCUSSION In this literature review and meta-analysis we assessed studies addressing communication between PCPs and patients regarding weight. Our literature review consistently demonstrated that physician advice can have a positive effect on patient action regarding weight loss. Our meta-analysis indicated that provider weight loss advice has a statistically significant impact on patient attempt to lose weight, suggesting that brief counseling by the provider may play a role in patient weight management. In our meta-analysis, comparison of data before and after the 1998 NHLBI guidelines did not find a significantly positive impact of guideline publication on the association between provider advice and patient weight loss efforts. Caution should be taken with these results as there were only two studies that used data before the 1998 guidelines, both of them larger studies using national or state-based data as opposed to smaller local studies. Caution should also be taken with our finding of a significant difference in patient report of weight loss attempt if advised by their PCP in adults versus children (OR ¼ 4.24, 95% CI 2.90, 6.22 versus 2.24, 1.69, 2.98, P ¼ 0.01), because of the small number and total n of studies including children. Further study is needed to better evaluate and identify a true significance in the difference we found in patient report of weight loss attempt between International Journal of Obesity (2013) 118 -- 128

patients who were surveyed by telephone compared with inperson (OR ¼ 5.50, 95% CI 3.46, 8.72 versus 3.00, 95% CI 2.15, 4.17, P ¼ 0.04). In-person surveys included both large national studies (NHANES and NHIS) that are conducted in person and smaller local surveys, whereas telephone surveys consisted solely of large national surveys, and these two may not be easily compared. We found no significant difference in the correlation between provider advice and weight loss attempt in obese-only versus mixed-weight samples in our meta-analysis. Again, there were a small number of obese-only studies, requiring caution with interpretation. Rodondi et al.39 and Sciammana et al.40 both report that obese patients, especially those with an obesity-related comorbidity, are more likely to receive weight loss advice from their physicians compared with overweight patients. However, Sciammana et al.40 found that patients in lower overweight body mass index categories were more likely to act on such advice compared with obese patients with a body mass index of X30 kg m - 2. Bish et al.41 had similar findings to those of Sciammana et al.40 and advise caution with these findings, as patients may have lost weight since receiving physician advice, or may have sought assistance with their weight from a medical professional because of feelings about their weight, regardless of their actual weight.39 Only studies assessing the correlation between provider weight loss advice and specific behavior change attempt related to physical activity demonstrated a negative correlation. This may be related to providers’ overall discomfort and limited knowledge of these topics.54,55 Importantly, we found that all studies that looked at the association between provider weight loss advice and actual patient weight loss found a positive association between the two. This positive association was found in studies of different sizes and populations. Furthermore, it was demonstrated in populations who received both advanced counseling and simple PCP recognition or diagnosis of overweight and obesity. Limitations This study contains several limitations. One is the small number of studies included in the meta-analysis. Because of repeat use of similar data sources or inappropriate outcome data, we were unable to use many potential studies. However, reliability is demonstrated by the relative consistency of the effect sizes and positive direction in nearly all studies. The meta-analysis contains studies of differing sizes and potentially of differing quality, possibly affecting outcomes. This is demonstrated further in the moderator analysis of national versus local studies, which essentially separates out studies with the smallest and largest sample sizes, but from which we found no significant difference. Meta-analysis calculations attempt to take into account study size when calculating effect size but cannot discern quality. However, all were published in peer-reviewed publications, many used wellvalidated surveys and techniques for obtaining subjects and our quality calculation revealed adequate agreement. Inability to obtain raw data led to use of studies with both adjusted and unadjusted data. However, adjusted ORs will tend to be smaller, underestimating the effect of the exposure rather than overestimating it. The use of the prevalence ratio instead of the OR to display effect size in one study26 tends to underestimate the effect size compared with the OR, giving little concern that this study would cause overestimation of the effect of the exposure on the outcome. As groups of studies were divided into various categories, the number of studies in each group (k) became small, which can lead to reduction in statistical power to detect significant differences, particularly in the case of random effects analyses.25 This study evaluates the effect of PCP advice on behavior change, potentially considered an intermediate outcome, whereas & 2013 Macmillan Publishers Limited


only five of seven studies evaluating the outcome of actual weight loss used independent data for meta-analysis. Because of this small number, the heterogeneity of these studies and the difference in their outcomes, meta-analysis of these studies would not provide meaningful data. However, examining patient behavior change in the context of provider advice is an outcome worthy of evaluation and the overwhelmingly positive outcomes should encourage more providers to talk to their patients about weight. Conclusions The rapidly growing prevalence of obesity and its associated risks have increased the importance of the role that the PCP can play. This study assesses the importance of weight loss advice by the PCP. We found that provider weight loss advice positively affects patient weight loss behavior in all outcomes addressed. More studies and interventions are needed to clarify the role of providers in this interaction and to overcome barriers to provider self-efficacy regarding counseling during the clinic visit. Policymakers should recognize the provider’s need for additional time and training in advising their patients as well as improvements in reimbursement and provision of tools such as dietitians. Perhaps most importantly, PCPs need to recognize their influence when it comes to advising their patients about their weight. CONFLICT OF INTEREST Dr Anderson currently has research support from Health Management Resources (HMR), and is a consultant to HMR.

ACKNOWLEDGEMENTS We thank James Meigs and Elisabeth Watkins for review and editing of this manuscript. We thank Heather Bush and Daisuke Sugimoto for assistance with biostatistical analysis and editing.

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