Our study shows that many primary care clinicians in the VA do not regularly counsel and refer obese patients to weight management services. The barrier most strongly related to providing diet and exercise counseling was poor obesity education during medical school and residency training programs. In fact, less than a third of respondents reported that they had learned good obesity management practices during medical school and residency training programs. This finding of poor nutrition, exercise, and behavioral counseling in medical and residency training programs has been corroborated in a number of previous studies [7
]. In our study, personal dietary vigilance by clinicians also impacted the likelihood of regularly calculating the BMI of obese patients, with more vigilant clinicians being more likely to calculate BMI. Previous studies, too, have found similar results in that physicians with a personal history of obesity or vegetarianism were more likely to provide nutrition and weight counseling to patients [28
]. Another study by Hash et al. [20
] concluded that patients were more receptive to health counseling given by nonobese physicians.
Contrary to previous studies [17
], our study did not find that clinicians feel that their weight loss efforts are futile. Our surveyed clinicians largely believed that many obese patients are ready for weight loss, that physician-delivered weight counseling can be successful, and that effective weight management tools are available.
Although a number of barriers identified in previous studies were confirmed in the current study, several barriers such as attitudes toward obese patients and lack of insurance payments for obesity care were not related to actual weight management practices. Insurance coverage may not have been a barrier since most veterans receiving care in the VHA have coverage for a wide array of services, including obesity-related services, unlike many patients found in the general population.
In addition, clinicians reported access to educational materials for obese patients, ability to refer patients to an obesity educator, dietician, physical therapist, behavioral counselor, and group obesity appointments, and use of a readiness to change questionnaire about weight loss for obese patients as useful weight management services for the VA to implement. Many of these services will be offered as the VHA's Managing Overweight and Obesity in Veterans Everywhere (MOVE!) Program is nationally rolled-out. The program is multidisciplinary in nature and includes five steps of care ranging from patient education to bariatric surgery provided by dieticians, behavioral counselors, obesity educators, clinicians, nurses, physical therapists, and surgeons.
Our study found that the context of weight management counseling practices vary, and that these practices differ by beliefs about obesity and by training level. Clinicians who believe obesity is a disease are more likely to counsel obese patients in a positive context than clinicians who do not believe obesity to be a disease. This may imply that clinicians who believe obesity to be a real clinical entity would be more compassionate towards obese patients than clinicians who feel that obesity is a character flaw or linked to lack of willpower. This finding supports that of Scott et al. [30
], who found that clinicians who were the most likely to counsel patients on weight management initiated conversations by "medicalizing" the obesity. Our results also showed that attending clinicians were more likely than resident physicians to counsel positively. Whether this finding is due to the years of experience of the attending physicians or to a shift in obesity counseling norms is indeterminable by this study. In addition, our sample sizes were very small in these analyses, and most context of counseling items required Fisher's Exact Tests for 2 × 2 analyses given the small cell sizes for several of the cells.
Other limitations of our study include our small response rate of resident physicians, our exclusion of nurses, and our sample of only one VAMC and one CBOC. This project served to pilot test our survey, which we plan to distribute to more VAMCs and CBOCs in the near future. We note that the generalizability of our findings may be limited to our region and therefore, should be interpreted with caution. In addition, our pilot study resources prohibited our study of nurses, although future studies are planned to identify obesity-related practices and barriers that nurses in the VA healthcare system face, given their important role in obesity management. High response rates from resident physicians are difficult to capture given their busy schedules and demands from other research projects. We recognize, however, that the residents most likely to have responded may be more conscientious than non-responders, and therefore the rates of various obesity practices may be over-inflated in this study. Nevertheless, our rates of most practices were sufficiently low to warrant additional attention to obesity management in the VA healthcare system. Lastly, due to time constraints, we were not able to perform all of the appropriate reliability testing on our survey instrument, such as test-retest reliability. We are currently conducting these tests and will have completed them before our next round of survey administration.
Our study does, however, have several strengths. For one, this is the first time primary care management of obesity has been examined empirically in the VA to our knowledge. Secondly, although we only gathered respondents from two settings, we did administer the survey to one large VAMC and one smaller CBOC, and also had respondents with two different training levels (attendings and residents). This mix of providers will help increase the reliability of our findings.