Advice from health care professionals to lose weight should be uniformly high for those with a serious weight problem, regardless of the proportion of obese persons in the population or the sociodemographic characteristics of the patient. We expected that as obesity prevalence rose in the population, coupled with growing awareness of its associated health problems, providers would devote more attention to weight loss advice, but in fact the opposite occurred. As prevalence of obesity increased, obese adults with a recent primary care visit were less likely to report being advised to lose weight.
Results of our adjusted analyses for 2000 were consistent with findings from other national studies using data from the same period,18,24
in particular, that lower rates of professional advice to lose weight were associated with youth, lower income, less education, and being male. Trend analyses showed that receipt of advice to lose weight was low for all subgroups in all years. Only diabetics exceeded an adjusted advice prevalence of 50% in any year; the only other groups to approach 50% were Asian and Pacific Islanders, those aged 50 to 64, and the college educated. However, the evidence of a growing divide in advice to lose weight between the richest and poorest and between the most and the least educated is cause for concern, particularly when obese persons in groups with the greatest obesity burdens are also the least likely to receive any professional intervention, even if they receive routine care. Moreover, the low and rapidly falling prevalence of advice to obese elderly persons, who are most at risk from chronic diseases, is an issue that merits urgent attention. Finally, the significant decline in advice reported by obese diabetics is worrisome, since weight control is a key factor in managing this chronic illness.
These findings are subject to several limitations. BRFSS does not sample persons living in institutions or persons living in households without a telephone. Persons living in households without a telephone may be less likely to receive professional advice regarding weight or regular health care and be more likely to be obese, as having a telephone reflects socioeconomic status. Prevalence estimates and trend data could have been affected by low response rates; however, BRFSS uses poststratification weights to minimize this problem.42
The race/ethnicity groupings available in BRFSS data do not allow any important differences between subgroups within these broad categories to be revealed. Another limitation is the use of self-reported, rather than measured, height and weight for determining obesity, the misreporting of which has been shown to be influenced by age, gender, and actual weight.47–49
However, there is no suggestion that this tendency has changed over time, and the tendency of individuals to underreport their weight49
increases confidence that those classified as obese by the BRFSS would be so classified through objective assessment. Finally, we had to rely on respondent self-report of professional advice to lose weight and receipt of a checkup within the previous year, both of which may suffer from imprecise recall or a tendency to report more socially desirable answers. Patients counseled about nutrition and exercise are more likely to recall the advice if the advice is of a relatively long duration or relevant to a current health problem.50
However, the possibility that advice recall may be biased simply underscores the likelihood that those who cannot remember being advised are no different in effect from those who were not advised at all, in that neither group received adequate counseling to be effective for weight loss. Also, there is no evidence that any such bias has changed over time.
This study is unique and important because it demonstrates that not only is there inadequate attention to weight loss for obese patients within a health care setting,18–23,26–30
but there is actually a downward trend in weight loss advice at the same time that the prevalence of obesity is increasing. The rapid increase in obesity prevalence may contribute to physicians' feeling that their efforts are fruitless. Moreover, the “fen-phen” controversy in the 1990s may have discouraged physicians from counseling their obese patients about weight loss, particularly if they felt that counseling without medications was ineffective, although this tendency might be countered by the growing popularity of bariatric surgery as a solution for the most obese patients.
The demand for preventive care services from physicians is so high as to preclude provision of all needed services in many circumstances, and new services are continually being recommended.51
In addition, counseling for diet, which is ranked by the U.S. Preventive Services Task Force (USPSTF) as less strongly evidence based than counseling for tobacco cessation or injury prevention,52
is also estimated to require the most time of any USPSTF-recommended counseling service.51
Finally, persons of low socioeconomic status have a greater burden of disease53–55
and are more prone to depression,56
which might leave little time during a routine visit to discuss nutrition, exercise, and weight loss. More study is needed to determine whether the link between low socioeconomic status and falling prevalence of reporting advice from a health care professional may be related to time pressure from increased preventive care demands, shifting professional beliefs about the efficacy of counseling for these individuals, developments in surgical and pharmaceutical options, or even to changes in the settings in which these persons seek care.
Studies have shown that professional advice and follow-up with obese patients influence their motivation to make changes in diet and exercise and may promote successful weight loss.20,21,36–40
There is a need for reimbursement mechanisms that allow providers to give their patients sufficient weight reduction counseling and that link this counseling with reimbursement for intensive, evidence-based, behavioral interventions to lose weight.28,34
Also, training in nutrition and exercise guidelines would give physicians a foundation for and perhaps a greater disposition toward addressing these problems with patients. Finally, given the difficulties in changing physician behavior, programs need to be developed that specifically target groups that are unlikely to be counseled regarding diet and exercise, and yet are at high risk for obesity or obesity-related chronic illnesses.