Barriers to obesity management: a pilot study of primary care clinicians
BMC Family Practice
Barriers to obesity management: a pilot study of primary care clinicians
Valerie Forman-Hoffman 1 2
Amanda Little 0
Terry Wahls 1 2
0 Carver College of Medicine, University of Iowa , Iowa City, IA , USA
1 Department of Internal Medicine, Carver College of Medicine, University of Iowa , Iowa City, IA , USA
2 Center for Research in the Implementation of Innovative Strategies in Practice (CRIISP) Iowa City Veterans Affairs Medical Center , Iowa City, IA , USA
Background: Obesity is an increasing epidemic in both the US and veteran populations, yet it remains largely understudied in the Veteran's Health Administration (VHA) setting. The purpose of our study was to identify barriers to the effective management of obesity in VHA primary care settings. Methods: Three focus groups of clinicians from a Veteran's Affairs Medical Center (VAMC) and an affiliated Community Based Outpatient Center (CBOC) were conducted to identify potential barriers to obesity management. The focus groups and previously published studies then informed the creation of a 47-item survey that was then disseminated and completed by 55 primary care clinicians. Results: The focus groups identified provider, system, and patient barriers to obesity care. Lack of obesity training during medical school and residency was associated with lower rates of discussing diet and exercise with obese patients (p < 0.05). Clinicians who watched their own diets vigorously were more likely to calculate BMI for obese patients than other clinicians (42% vs. 13%, p < 0.05). Many barriers identified in previous studies (e.g., attitudes toward obese patients, lack of insurance payments for obesity care) were not prevalent barriers in the current study. Conclusion: Many VHA clinicians do not routinely provide weight management services for obese patients. The most prevalent barriers to obesity care were poor education during medical school and residency and the lack of information provided by the VHA to both clinicians and patients about available weight management services.
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Background
Obesity is an increasing epidemic in both the general US
population [1] and veterans [2] and is an important
etiologic factor in heart disease, diabetes, arthritis, depression,
and various types of cancers [3,4]. It is estimated that
among the 6 million users of Veterans Health
Administration (VHA) services, 44% are overweight and an
additional 25% are obese [5]. Although the U.S. Veterans
Health Administration (VHA) is the largest integrated
health care system in the United States [6], obesity in this
setting has remained vastly understudied.
Despite numerous studies that have defined optimal body
mass index (BMI) targets for patients, numerous
providerlevel barriers exist to the effective management of obesity
in primary care. These barriers include lack of formal
training of primary care practitioners in nutrition, obesity,
and counseling on weight-related topics [7-12], perceived
inability to change patient behaviors [12], lack of known
effectiveness of treatments [8,13,14], negative attitudes
toward obese patients [15-17], beliefs that patients are not
interested or ready for treatment [9,12,19,20], and beliefs
that obesity is the responsibility of the patient [21]. In
addition, even though previous research has determined
that patients have more confidence in weight counseling
made by nonobese physicians, vegetarians, and those
who used to be obese [20] and that nurse's weight impacts
attitudes towards obesity and its treatment [19], it is
unclear how provider's personal weight and exercise
practices influence their obesity-related patient practices.
Even when providers do initiate health education and
dietary counseling, there is still some controversy over
whether these practices actually motivate patient
behavior. Although previous studies have determined that the
contextual framing of health behavior counseling in a
positive (i.e., emphasizing the benefits of weight loss)
versus negative (i.e., emphasizing the detriments of
remaining obese) manner affects patient's receptivity [22,23], it is
unknown whether framing style has an impact on the
successful implementation of weight-related
recommendations. Nonetheless, the manner by which clinicians
discuss obesity with patients does affect patients'
receptiveness to counseling [16], and even modest reductions
in weight can lead to significant health benefits [24,25].
For example, it is estimated that a 10% reduction in
weight can extend life expectancy an average of 27
months and can reduce lifetime medical expenditures of
associated chronic conditions (e.g., heart disease,
diabetes) by $2200$5300 [26].
In addition to provider-related barriers, several previous
studies have identified system-level barriers to obesity
care. These include lack of payment by insurance
companies for weight-related counseling and care [12,13,17],
lack of time during patient visits [9,12,13], lack of
available teaching m (...truncated)