We report three important findings. Physicians use some components of the Five A’s framework to deliver weight loss counseling. Physicians tailor the intensity of their counseling based on patient characteristics. Some components of the Five A’s seem to be related to patients changing their behaviors.
Despite receiving little or no formal training in the Five A’s for discussing obesity, we found that physicians were using at least some portion of the Five A’s technique in most encounters with overweight and obese patients. This did not seem to differ based on physicians’ training in obesity counseling. Physicians were more likely to Ask and Advise,
yet infrequently Assess, Assist, or Arrange. These findings are consistent with previous research in Five A’s counseling in primary care.17
Additionally, this finding mirrors what has been found in the smoking literature.23,24
The emphasis on advice is not surprising, given that physicians are trained in information giving and seeking (Ask and Advise) and are less frequently trained in more partnership building types of behaviors. Though Ask and Advise are more common, the problem with predominantly using these behaviors is that they do not help physicians learn what patients are actually willing to do, and the physicians may, therefore, not be able to help patients formulate an action plan for change. Though physicians appear to realize the importance of weight loss counseling and are attempting to counsel, they may be missing an opportunity to maximize impact.
Physicians seem to tailor their weight loss advice. Encouragingly, physicians provided more comprehensive counseling—used a greater number of Five A’s—with heavier patients, who perhaps need it more. This finding is consistent with previous research that has shown that physicians are more likely to target their counseling to heavier patients.17
Physicians also used more of the Five A’s with more motivated patients and with patients who reported less confidence to lose weight. Our own work indicates that physicians are reluctant to counsel patients who do not want to change.25
Findings from the current study suggest that physicians do more for those who need more, those who are less confident and are heavier, but also may choose to do more with patients with whom they think they will have the biggest impact, namely those who are motivated.
Overall, use of the Five A’s seemed to influence patients to be more motivated to change, more confident to change, and more likely to change. Improvements in motivation and confidence are important as they have been correlated with weight loss, weight maintenance, and continued behavior change over the long term.26,27
When physicians provide strong, clear advice, patients might be able to recognize the importance of weight as a health concern; the converse might be true when physicians do not provide advice.
Indeed, results suggest that patients whose physicians Assisted or Arranged showed improvements in actual dietary fat intake change scores. This modest improvement reflects a change in one fat-related eating behavior, like trimming the fat off of meat often instead of sometimes or by eating bread/rolls without butter or margarine less often, eating lower fat cheeses less frequently, or from switching from 2% to non-fat milk. These are minor dietary adjustments but ones that can reduce energy intake by 100 or 200 kcal/day, a deficit large enough to result in weight loss in some patients. Thus, the difference likely represents a clinically significant improvement. This supports the use of explicit planning by the physician-patient team in improving nutrition behavior. It may also reflect referrals for medical nutrition therapy, which are an important component of multi-disciplinary weight loss strategy. No changes were found for actual exercise, but this is not surprising as even intensive behavioral interventions are often unable to improve physical activity.28
Only one of the A’s was linked to actual weight loss. Patients whose physicians Arranged a follow-up visit were more likely to have lost weight 3 months following the visit. This is consistent with the notion that frequency of contact is an important element for influencing behavior change; it may reflect the patient’s feeling accountable to their physician. It is encouraging that physicians were more likely to Arrange a follow-up visit for patients with higher BMI.
A major strength of this study is that these primary care patients were not enrolled in a weight-loss trial and therefore were not self-selected to be highly motivated to lose weight. Another strength is the large and ethnically diverse sample. The study also has several limitations. First, the results may not generalize to younger, lower income patients. Second, the study was observational. Though we adjusted for a broad set of patient, physician, and visit covariates, unmeasured confounding variables may still account for at least part of the observed associations. Third, multiple comparisons were done, so significant associations with P values near 0.05 must be interpreted with caution. Fourth, there were low frequencies found for Assessing, Arranging, and Assisting. Although this is not surprising, the low frequencies of these techniques make it difficult to detect the effectiveness of these techniques on weight loss. Finally, the analysis is limited by the use of self-reported dietary fat and fiber intake and physical activity measures. A food diary and an accelerometer may have been more accurate; however, such involved measures could invoke changes in behavior, which would have made the interpretation of results more complicated.
This is the first study to assess the relationship between actual use of the Five A’s in weight loss counseling in the primary care encounter and subsequent weight-related behavior change. Physicians routinely Asked and Advised patients about weight; however, they rarely Assessed, Assisted, or Arranged. Next steps for this work would be to examine more closely whether some of the A’s are qualitatively more important than others. Further, given these preliminary results, a randomized controlled trial might be warranted to test an intervention that attempts to teach physicians how to incorporate the Five A’s in their weight loss counseling.