In summary, these data from a large, contemporary population sample illustrate that therapeutic lifestyle counseling remains suboptimally applied by health-care providers, with disparities in application most notable among (i) those without prevalent hypertension, hyperlipidemia, or diabetes, and (ii) ethnic minorities. These disparities in counseling about lifestyle modification demonstrate that health-care providers commonly fail to capitalize on an important opportunity for primary prevention through lifestyle intervention to impact the development of obesity-related morbidity, especially in black and Hispanic populations at high risk of developing cardiovascular disease (31
). The progressive increase in reported counseling on weight loss, dietary changes, and physical activity with an increasing number of prevalent CV risk factors seen in the DHS population supports the concept that comorbidities, as opposed to the presence of obesity, serve as the impetus for counseling on lifestyle modification. Biases that direct health professional counseling towards those with existing hypertension, hyperlipidemia or diabetes may contribute to a lack of awareness among obese individuals without CV risk factors that obesity itself is a risk factor for cardiovascular morbidity, potentially making them more likely to perceive themselves with a low lifetime risk of cardiovascular disease.
Our study suggests that counseling on lifestyle modification is substantially driven by the presence of cardiac risk factors, rather than by obesity itself, despite guideline recommendations that support lifestyle counseling in all obese individuals (14
). Data from the 1996 Behavioral Risk Factor Surveillance System (BRFSS) in over 12,000 obese subjects demonstrate that only 42% of obese individuals who visited a physician in the last 12 months reported counseling about weight loss. In this study, subjects with diabetes were more likely to report counseling than those without, suggesting bias towards preferentially counseling obese individuals with existing risk factors (8
). Further analyses of the 1996 BRFSS data demonstrated that while the presence of a weight-related comorbidity predicted whether an individual reported counseling, only 47% of those with a BMI ≥30 kg/m2
and with hypertension, diabetes, or hypercholesterolemia reported counseling to lose weight (19
). However, these data were collected prior to the publication of guidelines for counseling in obesity by the National Institutes of Health in 1998 or by the US Preventive Services Task Force in 2003 (14
Unfortunately, establishing guidelines does not appear to have meaningfully improved physician counseling rates. Despite the dramatic increase in obesity prevalence over the past decades, studies of more contemporary cohorts demonstrate that less than half of obese individuals, even among those with BMI at or above 40 kg/m2
, report receiving specific advice on weight loss, with prevalent diabetes and hypertension serving as independent predictors of reported counseling (32
). In addition, comparison of trends in counseling from samples of the US population in the BRFSS have shown a concerning decline in reported weight loss counseling from 1994 to 2000 (11
), with only 44% of obese adults from 11 states reporting counseling in 2005 (27
). In the DHS, we found that 62% of obese individuals seen by a physician in the past year reported physician counseling to lose weight. The higher percentage of individuals reporting counseling on weight loss in the DHS population compared to random samples of the US population likely reflects a higher prevalence of diabetes, hypertension or hyperlipidemia in the DHS population compared to the previously sampled populations (32
), regional variation in medical practice, and differences in data collection between the studies. These findings suggest that counseling to lose weight remains underutilized in the treatment of obesity, and interventions should be developed to encourage physicians to counsel all obese individuals about lifestyle modification based on established guidelines, regardless of the absence of comorbidities.
Prior studies have not recognized race/ethnicity as an important determinant of whether obese patients report counseling for lifestyle changes, with several studies showing that race is not an independent predictor of lifestyle counseling (8
). Others have reported higher rates of counseling on lifestyle modification among ethnic minority populations (9
), although individuals with obesity were not the primary focus of all of these studies (25
). Most have not taken into account that blacks and Hispanics may have more prevalent factors that lead to counseling (8
). Among women in the 2000 BRFSS survey, Mack et al
. identified that 44% of black women with obesity reported counseling to lose weight as compared to 40% of obese white women and 43% of obese Hispanic women, suggesting that obese black and Hispanic women were actually more likely to be counseled than were white women (9
). However, black and Hispanic women were also more likely to have diabetes in this cohort, which likely drove the higher rates of weight loss counseling. Stratification of the DHS cohort by race/ethnicity allows us to ascertain that, while those with CV risk factors are counseled similarly across racial/ethnic groups, black and Hispanic men and women without risk factors are less likely to report counseling. Given that blacks and Hispanics are more likely to be obese (2
), and, therefore, more likely to suffer the cardiovascular sequelae of this disease (31
), it is imperative that lifestyle modification be promoted in these most vulnerable populations even before factors develop. This distinction also provides valuable insight into groups that might benefit from focused interventions to better promote lifestyle modification.
More frequent counseling on lifestyle modification, particularly among blacks and Hispanics with obesity, may lead these high risk subgroups to a better understanding of the health effects of obesity. Data from overweight and obese individuals from United States community health centers suggest that while blacks and Hispanics were less likely to perceive excess weight as damaging to health as compared to whites, blacks and Hispanics who were counseled about being overweight or obese by their provider were four-fold and over ten-fold, respectively, more likely to perceive that excess weight impacted health (12
). Another analysis of the 2000 BRFSS data revealed that advice to lose weight is an independent predictor of attempted weight loss among obese individuals (10
). Simple acknowledgement of weight status and lifestyle counseling appear to be associated with a more realistic perception of the effects of obesity and motivation for weight loss (13
); therefore, improvements in counseling may prove beneficial for an obese population without existing CV risk factors.
A key strength of our study is the large, diverse population-based study cohort of the DHS, which fosters the extrapolation of these findings to other contemporary multi-ethnic urban populations. In addition, we used measured height and weight, allowing a more accurate representation of the obese population in DHS, in contrast to a number of older studies that relied on survey data of self-reported height and weight to estimate BMI (8
). More recent studies of health professional counseling on lifestyle changes, however, are beginning to use measured height and weight to calculate BMI (21
). The limitations of this study must also be considered. These data are cross-sectional and, therefore, we cannot infer causality in our findings. Reported counseling cannot be independently and objectively verified from medical records; therefore, we are unable to know if DHS participants actually received lifestyle counseling. Health-care professionals’ characteristics, such as physician specialty, are not available for the participants who reported counseling, and these unmeasured factors may explain some variability in counseling. In addition, limited English proficiency may serve as a barrier and a potential confounder for lifestyle counseling among Hispanic participants; however, prior data from the National Health Interview Survey suggest that English proficient Hispanics have higher rates of obesity than Hispanics with limited English (34
). Finally, reported counseling data are subject to recall bias, and may not precisely reflect actual rates of counseling for all subjects. However, those who cannot recall counseling may be similar to those who were never counseled at all, as counseling on lifestyle modification is unlikely to change health beliefs and behaviors for those who do not remember its occurrence.
In conclusion, health professional counseling for lifestyle modification is underutilized in all obese individuals without cardiovascular risk factors, particularly among racial/ethnic minority populations. Education efforts to improve health professional counseling on lifestyle modification must focus on both clinicians and patients, encouraging health-care providers to counsel all obese patients about lifestyle modification as current guidelines recommend. Patients must be better educated about obesity as a cardiovascular risk factor and its impact on lifetime CV risk. Health professional counseling better targeted at obese individuals without other CV risk factors may help reduce persistent disparities in obesity prevalence and related CV comorbidities among blacks and Hispanics.