This study provides nationally representative data describing energy-balance clinical practices among U.S. PCPs regarding their adult patients’ diet, physical activity, and weight control. Results suggest that PCPs’ energy-balance clinical practice is fairly low and needs improvement. While the majority of PCPs report regularly assessing weight and height, less than half are converting that information into BMI. Similarly, while most PCPs report providing some kind of counseling, less than half always provide specific guidance, even for patients who have weight-related chronic conditions. Few PCPs consistently refer patients for further management or systematically track these behaviors over time, although more PCPs provide care and management for patients with chronic disease than those without. However, almost three quarters of physicians report ever prescribing pharmacologic treatments for weight control and even more (almost 90%) report having ever referred a patient for surgical procedures for obesity. These data track with increases in surgery and drug treatments seen in national studies28,29
. Taken together, the current data, although consistent with prior research6, 9,10, 12,13, 15, 18
, suggest a need to understand reasons for low levels of energy-balance clinical practices in primary care settings.
Clinical guidelines3, 30,31
and the Surgeon General19,20
, emphasize the need for physicians to screen for overweight/obesity. Although NIH guidelines3
provide detailed evidence and guidance for assessing and treating overweight and obesity, and have been endorsed by more than 50 medical and professional groups, PCPs receive mixed messages about counseling on diet and physical activity from other organizations. The U.S. Preventive Services Task Force and The Task Force on Community Preventive Services, for example, have found insufficient evidence related to the effectiveness of low-level provider-oriented diet and physical activity interventions for obesity or training for such interventions.30–32
The current data suggest that PCPs are not following NIH guidelines, particularly with respect to BMI screening. One possibility is that weight change (not BMI) is used to determine when to counsel about weight, or that PCPs do not want to use BMI defined labels such as obese or overweight with their patients. This may change, as BMI became a required HEDIS measure in 200933
, just after the EB-PCP survey was fielded. Future research that documents why physicians are less likely to assess BMI than weight is needed.
In the current study, several factors were associated with PCPs’ clinical practices, and a few were particularly interesting. Consistent with previous research, the current study identified gender34,35
and specialty9, 36
differences. OB/GYNs were least likely to counsel their patients on diet, physical activity, or weight control. One reason may be because they feel they need additional training37
. OB/GYNs also were least likely to record BMI, which is concerning, given the focus on BMI in recent guidance on weight gain during pregnancy.38
Irrespective of specialty, all PCPs were more likely to guide patients on physical activity than on diet or weight control, and more likely to provide guidance on diet than weight. This finding also was seen among PCPs who treat children (Huang et al., this issue). It is possible that physical activity is easier to discuss than diet, given the complexity of dietary recommendations and prior research suggests that health professionals are uncomfortable discussing weight or demonstrate weight-based stigmatization toward patients39,40
. In the current study PCPs were more likely to intensively manage diet, physical activity, and weight control in patients with chronic disease than those without. Physicians may be concentrating on patients with the greatest problems while missing important prevention opportunities. Previous research has also documented a variety of barriers related to counseling including physician’s perceptions of insufficient skills or training, lack of time, lack of office supports, and perceptions that patients will not be able to change behaviors.15, 41,42
Future analyses from this survey will document whether these are barriers for U.S. physicians. Overall, results from the current analysis suggest that training, assessment and communication tools, and referral options are needed to increase the number of PCPs who routinely include diet and weight control in patient care.
This study has some important strengths and limitations. A notable limitation is the self-reported nature of the data. However, the current results are consistent with research that has examined physician patient discussions of diet, physical activity and weight control from various vantage points, including from the patient’s perspective,6, 11,12
from the physician’s perspective,9,10, 13, 15, 18
and in chart reviews of individual visits.7, 16, 20
Although it is not possible to directly compare the outcomes of these studies, they suggest that regardless of the unit of analysis, physician-initiated energy-balance clinical practice is not happening frequently. Important strengths of this study are that it provides current, nationally representative data derived from a survey with close to a 70% response rate. These data have implications for health policy and needed resources. For example, stronger messages requiring routine BMI assessment are needed, such as the newly enacted BMI HEDIS measure.33
A focus on energy-balance clinical practices in medical school and continuing education training should be considered. Greater linkage between PCPs and providers of ancillary medical services, such as nurses, dietitians, or exercise specialists, may be necessary to increase obesity prevention and treatment services. Improved tools are needed for assessing diet, physical activity, and weight control, as well as specific applications for their use in energy-balance clinical practices. Increased support for electronic medical records may assist clinicians in more readily assessing, tracking, and referring patients. Further, health policy related to payment reform may be needed to support reimbursement for energy-balance clinical practices.
In sum, the EB-PCP study provides an important indicator of current U.S. PCP energy-balance clinical practices in the areas of diet, physical activity and weight control of adult patients. Although most clinicians are providing some care in this area, they have much room for improvement. Additional research is needed to understand factors that influence PCPs’ energy-balance clinical practices. Data from the EB-PCP will be further explored to determine whether personal experiences (e.g., PCPs own diet and exercise behaviors, attitudes, and knowledge of guidelines), professional barriers (e.g., patient load) or external factors (e.g., staffing, reimbursement, practice-level policies and administration) help explain differences in clinical practices.