This study updates earlier research related to PCP perspectives on the causes of obesity and examines physician-reported causes of obesity and solutions for improving obesity care, for PCPs overall and by years since medical school completion. Like previous research,6
we found that PCPs overwhelmingly identified individual behavioural factors (eg, poor diet and physical inactivity) as important causes of obesity. PCP perspectives on improving obesity care supported additional training (eg, nutrition and exercise counselling) and practice-based changes (eg, including BMI in the patient chart). We observed few differences in PCP perspectives about the causes of obesity or solutions to improve care, regardless of when they completed medical school. However, we found PCPs who graduated from medical school within the past 20 years, compared with those with graduated more than 20 years ago, more frequently recognised social determinants as causes of obesity, such as lack of information about good eating habits and lack of access to healthy food. While PCPs who completed medical school more recently reported feeling more successful helping obese patients lose weight, these successful providers are still a minority. This is consistent with research suggesting that PCPs generally feel unprepared to care for obese patients.7
Increased time since completing medical school could lead to more negative attitudes towards obesity care, as physicians may become frustrated by years of failed attempts to help their obese patients lose and maintain weight. Regardless of when PCPs completed medical school, they overwhelmingly supported additional training and practice-based changes to help them improve their obesity care.
The limited differences among PCPs that we observed may suggest that obesity-related training has changed little over time. We found little evidence that any recent emphasis on obesity-related training in medical school has translated into significant differences in self-perceived competency. Interestingly, while most PCPs reported competence in diet and exercise counselling to obese patients, less than half-reported success in helping those patients lose weight.
Given that obesity training has been shown to improve obesity care,12
improvements to medical and postgraduate medical education are critical. As most practising PCPs report inadequate training in obesity care, these physicians may be particularly receptive to continuing medical education in this area.13
PCPs in our study desired additional training on nutrition and exercise counselling, care related to bariatric surgery patients, as well as motivational interviewing. Enhancements to medical education could potentially help improve obesity care given research suggesting consistency between physician beliefs about solutions and causes;29
for example, physicians who endorse medical solutions for obesity typically believe obesity is caused by biological factors. In addition to addressing these gaps in medical education, we should consider transitioning some obesity care responsibilities away from PCPs to nutritionists/dietitians. Physicians in our study identified these health professionals as being most qualified to help obese patients lose or maintain their weight. Furthermore, incentives for care coordination under the Patient Protection and Affordable Care Act such as the Patient Centered Medical Home recommend the inclusion of dietitians as members of health teams to support primary care practices.30
Perhaps a new model of obesity care should join PCPs, nutritionists, and other relevant health professional together—an approach which proved effective in the recently completed POWER trial,31
which examined the effects of behavioural weight-loss interventions among obese patients.
Future research is needed to better understand which components of obesity care would be best handled by PCPs and which components of obesity care would be best handled by nutritionists/dietitians. Recent work identifies successful models that include delivery of weight loss support by trained coaches via remote means (eg, telephone, email, and web-based modules, self-monitoring tools and feedback) along with PCP support31
and lifestyle counselling plus meal replacement or weight-loss medication chosen in consultation with the PCP.32
Regardless of their years after medical school completion, most physicians desired practice-based changes to facilitate improved obesity care. Physicians endorsed using appropriate medical equipment to accommodate obese patients, as well as documenting BMI in the chart as important practice changes. Such changes would ensure accurate identification and proper care of obese patients. Finally, the practice could better support obesity counselling by including diet and exercise tips in the chart for the physician to use.
There are several limitations to this analysis. First, our measures of physician attitudes do not represent the full possible spectrum of attitude measures in the literature (such as perceived skills33
or comfort in caring for obese patients34
) which may bias our results towards the null. Second, some of the included PCP's may have had extensive additional training in obesity (considering themselves ‘obesity specialists’), which could have biased our results positively. Years since medical school completion is a proxy for type of education they received, but we are unable to account for the huge variation in curricula across medical schools. Third, even though they survey was reviewed by experts in the field of obesity and primary care as well as pilot tested for comprehensibility, it is possible that physicians differentially interpreted some of the questions. Fourth, the response rate may limit the generalisability of these results to all PCPs in the USA.
In conclusion, this study suggests few differences in PCP perspectives about the causes of obesity or solutions to improve care of obese patients, regardless of when they completed medical school. The differences we did observe suggest that physicians with fewer than 20 years since completion of medical school more frequently recognised social determinants as causes of obesity and also reported feeling more successful helping obese patients lose weight. The results from the recently completed POWER trial, suggest that having PCPs play a supportive role to weight loss health coaches—such as reviewing patient progress and using this information to provide basic guidance and motivation—may be one effective model.31
In order to begin improving obesity care, medical education should focus on enhancing those obesity-related skills PCPs feel most qualified to deliver as well as changing the composition of healthcare teams and practice resources.