Preventive Medicine 99 (2017) 128–133

Contents lists available at ScienceDirect

Preventive Medicine

journal homepage: www.elsevier.com/locate/ypmed

Adult obesity management in primary care, 2008–2013

Stephanie L. Fitzpatrick a,⁎, Victor J. Stevens b
a
Department of Preventive Medicine, Rush University Medical Center, Chicago, IL, United States
b
Center for Health Research, Kaiser Permanente Northwest, Portland, OR, United States

a r t i c l e i n f o a b s t r a c t

Article history: In the U.S., the occurrence of weight counseling in primary care for patients with obesity decreased by 10% be-
Received 28 July 2016 tween 1995–1996 and 2007–2008. There have been several national recommendations and policies to improve
Received in revised form 17 February 2017 obesity management since 2008. The purpose of this study was to examine the rates of body mass index (BMI)
Accepted 18 February 2017
screening, obesity diagnosis, and weight management counseling in the U.S. from 2008 to 2013.
Available online 21 February 2017
The National Ambulatory Medical Care Survey visit-level data for adults 18 and over with a primary care visit dur-
Keywords:
ing survey years 2008–2009, 2010–2011, and 2012–2013 was included in the analyses using SAS v9.3. Study out-
Obesity comes included percent of visits with: BMI screening; obesity diagnosis; and weight counseling. We compared
Primary care survey years on these outcomes using 2008–2009 as the reference as well as examined patient and practice-
Weight management counseling level predictors. Analyses were conducted from 2015 to early 2017.
Of the total 55,608 adult primary care visits sampled, 14,143 visits (25%) were with patients with obesity. BMI
screening significantly increased between 2008–2009 and 2012–2013 from 54% to 73% (OR = 1.75, 95% CI
1.28–2.41); however, percent of visits with an obesity diagnosis remained low at b30%. Weight management
counseling during visits significantly declined from 33% to 21% between 2008–2009 and 2012–2013 (OR =
0.62, 95% CI 0.41–0.92).
Despite emerging recommendations and policies, from 2008 to 2013, obesity management in primary care
remained suboptimal. Identifying practical strategies to enforce policies and implement evidence-based behav-
ioral treatment in primary care should be a high priority in healthcare reform.
© 2017 Elsevier Inc. All rights reserved.

1. Introduction
More than one-third of adults in the U.S. have a body mass index
[BMI] ≥ 30 kg/m2 and are therefore at substantially increased risk
for diabetes and cardiovascular disease (CVD) (Flegal et al., 2012;
Ogden et al., 2014). Behavioral weight management treatment is
an effective first-line treatment for obesity with an average initial
weight loss of 8–10%, which is associated with a significant reduc-
tion in risk for diabetes and improvement in CVD risk factors
(Butryn et al., 2011; Wadden et al., 2012). However, in 2005–
2006, two-thirds of U.S. patients with obesity were not offered or
referred to weight management treatment during their primary
care visit (Ma et al., 2009). In addition, the rate of weight manage-
ment counseling in primary care significantly decreased by 10%
(40% to 30%) between 1995–1996 and2007–2008 (Kraschnewski
et al., 2013).
There have been several national recommendations and policies
implemented since 2008 to improve obesity management in pri-
mary care. The U.S. Preventive Services Task Force (USPSTF)
⁎ Corresponding author at: Center for Health Research, Kaiser Permanente Northwest,
3800 N. Interstate Ave., Portland, OR 97227, United States.
E-mail address: Stephanie.L.Fitzpatrick@kpchr.org (S.L. Fitzpatrick).
(Moyer, 2012), and a joint statement by the American Heart Asso-
ciation, American College of Cardiology, and The Obesity Society
(Jensen et al., 2013) recommend that physicians screen for over-
weight and obesity in their practices and provide or refer patients
with risk factors for cardiovascular disease to intensive behavioral
counseling. In 2011, the Centers for Medicare & Medicaid Services
(CMS) passed a decision to reimburse primary care physicians for
delivering intensive behavioral therapy to treat patients with obe-
sity (DHHS Centers for Medicare and Medicaid Services, 2012). The
CMS reimbursement policy is limited to coverage for Medicare
beneficiaries and only reimburses primary care practitioners.
When delivering the intensive behavioral therapy for obesity, phy-
sicians are expected to follow the 5 A's counseling framework (i.e.,
Assess, Advise, Agree, Assist, Arrange) (DHHS Centers for Medicare
and Medicaid Services, 2012; Vallis et al., 2013; Alexander et al.,
2011) with 10–15 min visits (maximum of 22 visits).
In addition, CMS implemented the Electronic Health Record (EHR)
Meaningful Use Incentive Program, where physicians receive financial
incentives when they implement and use the EHR to document quality
improvement measures (Centers for Medicare and Medicaid Services,
2013). Physicians are incentivized to document in the EHR BMI and a
follow-up treatment plan to provide or refer the patient with BMI ≥ 25
to weight management treatment.

http://dx.doi.org/10.1016/j.ypmed.2017.02.020
0091-7435/© 2017 Elsevier Inc. All rights reserved.
 S.L. Fitzpatrick, V.J. Stevens / Preventive Medicine 99 (2017) 128–133 129

The purpose of this study was to examine rates of patient BMI
screening, obesity diagnosis, and provision of treatment for obesity by
primary care physicians in the U.S. from 2008 to 2013 as well as exam-
ine the patient and practice characteristics associated with these
outcomes.
2. Methods
3. Results
There were 13,075 adult primary care visits sampled from 2008–
2009, 10,951 from 2010–2011, and 31,582 visits sampled from 2012–
2013. Of the total 55,608 adult primary care visits sampled, 14,143 visits
(25%) were with patients with obesity. Table 1 presents the weighted
proportions for visit, patient, and practice characteristics by survey year.

The National Ambulatory Medical Care Survey (NAMCS) is an annual

survey conducted by the National Center for Health Statistics that is
used to characterize the utilization and provision of ambulatory care Table 1
in the U.S. (National Center for Health Statistics, 2016a). Currently, Patient, practice, & visit characteristics of U.S. adult primary care visits by survey year: %a,
there is survey data publicly available from 1973 to 2013. A multi- (95% CI).

stage probability sampling design is used, which consist of sampling 2008–2009 (n 2010–2011 (n 2012–2013 (n
from primary sampling units (e.g., counties), physicians within the pri- = 13.075) = 10.951) = 31.582)
mary sampling units, and patient visits within practices. Using the med- Age group, y
ical chart (paper and/or electronic), physicians, office staff, or Census 18–44 29.0 (27.9, 30.0 (27.9, 27.7 (26.4,
Bureau representatives complete physician and patient record survey 30.8) 32.2) 29.0)
forms regarding: outpatient practice characteristics, physician demo- 45–64 38.1 (36.8, 38.3 (36.8, 38.3 (37.3,
39.5) 39.7) 39.3)
graphics, and visit-level data including patient demographics, reasons
65 and up 32.9 (30.8, 31.7 (29.3, 34.0 (32.6,
for the visit, diagnoses, and treatment. In terms of obesity-related 35.0) 34.1) 35.4)
data, the patient record form allowed surveyors to write in the patient Sex
height and weight, a checkbox to indicate diagnosis of obesity, and a Female 59.8 (58.1, 57.0 (55.1, 57.3 (56.1,
61.4) 58.8) 58.5)
checkbox to indicate if health education was provided (e.g., diet/nutri-
Male 40.2 (38.6, 43.0 (41.2, 42.7 (41.5,
tion, exercise, or weight reduction). In 2008–2009 and 2010–2011, the 41.9) 44.9) 43.9)
survey was completed using a paper form. However, in 2012–2013, sur- Race/ethnicity
veys were completed mostly by Census representatives using a comput- White non-Hispanic 74.9 (71.7, 73.4 (69.3, 73.0 (70.9,
er form (National Center for Health Statistics, 2016b). Each visit was 78.1) 77.4) 75.2)
Black non-Hispanic 10.0 (7.7, 12.3) 12.7 (9.6, 15.9) 10.1 (8.9, 11.2)
weighted in order to obtain national estimates.
Hispanic 11.0 (8.7, 13.4) 9.2 (6.0, 12.5) 12.5 (10.7,
Similar methods applied in Ma et al. (2009) and Kraschnewski et al. 14.3)
(2013) to examine previous NAMCS survey year data were used in this Other 4.1 (2.7, 5.5) 4.7 (3.0, 6.3) 4.4 (3.6, 5.2)
study. We used survey years 2008–2009, 2010–2011, and 2012–2013 Body mass index ≥ 30 20.4 (18.4, 21.4 (18.9, 28.9 (28.2,
visit-level data with adults 18 and over who had an office-based outpa- kg/m2 22.4) 23.9) 29.6)
Risks for obesity-related
tient visit with a general, family, or internal medicine physician. Because
disease/mortality
community health center visits were excluded in the 2012–2013 sur- Low 21.3 (19.6, 20.5 (18.7, 20.2 (19.0,
veys, community health center visits in survey years 2008–2009 and 22.9) 22.4) 21.3)
2010–2011 were removed from the analytic dataset (National Center Moderate 55.4 (54.0, 55.5 (53.9, 57.2 (56.2,
for Health Statistics, 2016b). Using the criteria specified in Ma et al. 56.9) 57.0) 58.3)
High 23.3 (21.6, 24.0 (21.9, 22.6 (21.6,
(2009), patients with diabetes or coronary artery disease were consid- 25.0) 26.1) 23.6)
ered at high risk for obesity-related disease complications and mortali- Insurance
ty. Patients with any one of the following conditions were classified as Private 57.7 (54.9, 53.8 (50.4, 50.8 (48.9,
moderate risk: a) hypertension, b) hyperlipidemia, c) sleep apnea, or 60.5) 57.1) 52.6)
Medicare 29.2 (27.0, 31.5 (29.0, 33.9 (32.3,
d) asthma. Patients with no cardiovascular disease risk factors besides
31.5) 34.1) 35.4)
obesity were considered to be at low risk for obesity-related complica- Medicaid 5.8 (4.3, 7.4) 7.2 (5.9, 8.5) 7.9 (6.7, 9.0)
tions and mortality. We compared survey years using a multivariable lo- Other 7.2 (5.5, 9.0) 7.5 (5.9, 9.2) 7.5 (6.2, 8.7)
gistic regression model on the following study outcomes using 2008– Electronic medical record
2009 as the reference time period: 1) percent of visits with height system
No 46.7 (40.5, 37.8 (32.3, 23.3 (20.3,
and/or weight measured; 2) among patients with BMI ≥ 30, percent of 52.9) 43.3) 26.3)
visits with obesity diagnosis; and 3) among patients with obesity, rate Yes, part paper part 14.4 (9.8, 19.0) 9.3 (5.7, 12.9) 11.6 (9.0, 14.2)
of any weight-related education (i.e., any combination of diet/nutrition, electronic
exercise, and/or weight reduction education selected on the patient re- Yes, all electronic 38.9 (32.3, 52.8 (47.4, 65.1 (61.6,
45.4) 58.3) 68.6)
cord form). In the model we adjusted for patient and practice-level var-
Region
iables that were found to be associated with these obesity-related Northeast 16.1 (11.1, 19.8 (15.8, 19.3 (17.7,
metrics in previous studies (Ma et al., 2009; Kraschnewski et al., 2013; 21.1) 23.8) 20.9)
Ahmed et al., 2016). These variables included sex, age, race/ethnicity, in- Midwest 25.8 (20.0, 24.2 (20.0, 19.8 (18.5,
surance type, level of risks for obesity-related diseases or mortality, if 31.6) 28.4) 21.0)
South 37.9 (31.9, 35.1 (30.0, 36.2 (34.4,
the patient had been seen before, use of electronic medical records in
43.8) 40.2) 38.0)
the practice, and region of the U.S. in which the practice was located. West 20.2 (15.6, 20.9 (17.2, 24.8 (22.9,
Given that predictors of BMI screening, obesity diagnosis, and any 24.9) 24.6) 26.6)
weight-related education were similar across years (data not shown), Height & weight measured
Neither 11.2 (9.0, 13.4) 10.3 (8.0, 12.5) 8.1 (6.8, 9.3)
we combined all survey years to increase sample size in order to exam-
Either 34.6 (30.3, 33.8 (29.2, 18.7 (16.7,
ine predictors of the outcomes for 2008–2013 (as one data point) using 38.9) 38.5) 20.8)
the same patient and practice-level characteristics previously men- Both 54.1 (50.0, 55.9 (50.6, 73.2 (70.8,
tioned. Analyses were conducted from 2015 to early 2017 using PROC 58.7) 61.2) 75.5)
SURVEYFREQ AND SURVEYLOGISTIC in SAS v9.3. Two-sided P a
All percentages are population percentages estimated from a weighted analysis taking
values b 0.05 were considered significant. into account the complex sampling stratification and clustering.
130 S.L. Fitzpatrick, V.J. Stevens / Preventive Medicine 99 (2017) 128–133

3.1. BMI screening
The measurement of both height and weight significantly increased
between 2008–2009 and 2012–2013 from 54% to 73% (OR = 1.75, 95%
CI 1.28–2.41) while adjusting for patient and practice-level characteris-
tics. Independent predictors of both height and weight being measured
included: a) Hispanic ethnicity compared to White non-Hispanic
(OR = 1.29, 95% CI 1.06–1.56); b) moderate risk (OR = 1.12, 95% CI
1.01–1.24) and high risk for obesity-related disease complications and
mortality (OR = 1.30, 95% CI 1.14–1.49) compared to low risk; c) Med-
icaid compared to private insurance (OR = 1.28, 95% CI 1.02–1.59); and
d) presence of all electronic medical records (OR = 1.58, 95% CI 1.25–
2.00) or part paper and part electronic (OR = 1.75, 95% CI 1.28–2.41)
versus no electronic records (Table 2). It should be noted that there
was a significant increase in the use of electronic medical records be-
tween 2008–2009 and 2012–2013 (OR = 2.48, 95% CI 1.66–3.71). Pa-
tients with Medicare versus private insurance and established patients
(seen before in the clinic) versus new patients were less likely to have
both height and weight measured during the visit (Table 2).
3.2. Obesity diagnosis and weight management counseling
Fig. 1 presents the weighted percentage of visits with obesity diag-
nosis, diet/nutrition education, exercise education, weight reduction
education, or any combination of weight-related education among visits
where a patient had a BMI ≥ 30. Across the years there was a non-signif-
icant decline in diagnosis and each specific domain of health education
(Fig. 1). There was a significant decline of 33% to 21% in any combination
of weight-related education between 2008–2009 and 2012–2013
(OR = 0.62, 95% CI 0.41–0.92). Women compared to men (OR = 1.41,
Table 2
Predictors of body mass index screening, 2008–2013.
Adjusted OR (95% CI)
95% CI 1.29–1.53), Black non-Hispanic compared to White non-Hispanic
(OR = 1.47, 95% CI 1.21–1.79), moderate (OR = 1.91, 95% CI 1.62–2.26)
and high risk patients (OR = 4.76, 95% CI 3.97–5.70) compared to low
risk, patients age 18–44 (OR = 2.34, 95% CI 1.86–2.94) or 45–64
(OR = 1.87, 95% CI 1.56–2.24) compared to patients 65 and older, pa-
tients with Medicaid compared to those with private insurance
(OR = 1.23, 95% CI 1.04–1.46), as well as established patients compared
to new (OR = 1.30, 95% CI 1.12–1.52) were more likely to have a diag-
nosis of obesity documented in their medical record (Table 3).
Weight management counseling was more likely to occur for pa-
tients who, identified as Black non-Hispanic (OR = 1.47, 95% CI 1.06–
2.03), Hispanic (OR = 1.39, 95% CI 1.08–1.79) or “Other” for race/eth-
nicity (OR = 1.62, 95% CI 1.08–2.43), moderate (OR = 1.30, 95% CI
1.02–1.65) and high risk (OR = 1.69, 95% CI 1.28–2.22), and had an obe-
sity diagnosis documented in their medical record (OR = 3.37, 95% CI
2.88–3.95) (Table 4). Visits where weight management counseling oc-
curred were, on weighted average, 21.95 (95% CI 21.04–22.86) minutes
long.
3.3. Obesity management for Medicare beneficiaries only
Because most of the policies to improve obesity management in pri-
mary care have been commissioned by CMS, we examined visits among
Medicare beneficiaries only. There was a total of 16,620 primary care
visits sampled with Medicare beneficiaries from 2008 to 2013 and
3863 (23%) of these were with patients with obesity. Percent of visits
with both height and weight measured increased from 49% to 72% be-
tween 2008–2009 and 2012–2013 (OR = 1.57, 95% CI 1.05–2.34).
Among visits with patients with Medicare and BMI ≥ 30, there was a
non-significant decline in percent of visits with an obesity diagnosis
(31% to 24%) and a non-significant decline in percent of visits with
any combination of weight-related education (28% to 20%) between
2008–2009 and 2012–2013.

Survey years 4. Discussion

2008–2009 1.00 [reference]
2010–2011 1.04 (0.83–1.31) NAMCS data between 2008–2009 and 2012–2013 indicated a signif-
2012–2013 1.75 (1.28–2.41)
Age group, y
icant increase in BMI screening (i.e., measure of both height and
18–44 1.09 (0.95–1.24) weight); however, the percent of visits with a documented obesity diag-
45–64 1.02 (0.92–1.14) nosis declined by 5 percentage points (30% to 25%). Despite emerging
65 and up 1.00 [reference] national recommendations and healthcare policies, provision or referral
Sex
to weight management counseling significantly declined from 33% to
Female 1.04 (0.97–1.11)
Male 1.00 [reference] 21% between 2008–2009 and 2012–2013. Medicare beneficiaries had
Race/ethnicity similar increases in BMI screening and decreases in obesity diagnosis
White non-Hispanic 1.00 [reference] and weight management counseling compared to the total population.
Black non-Hispanic 1.21 (0.93–1.58) There was a significant increase in practices with electronic medical
Hispanic 1.29 (1.06–1.56)
Other 1.18 (0.88–1.58)
records, which was a predictor of both height and weight being mea-
Risks for obesity-related disease/mortality sured. Most electronic medical records allow easy input of vital signs
Low 1.00 [reference] and automatic calculation of BMI. Other practice characteristics that
Moderate 1.12 (1.01–1.24) predicted measurement of both height and weight included Hispanic
High 1.30 (1.14–1.49)
ethnicity, Medicaid insurance, and moderate and high risks for obesi-
Insurance
Private 1.00 [reference] ty-related diseases and mortality. Established patients or patients with
Medicare 0.82 (0.72–0.92) Medicare were less likely to have both height and weight measured.
Medicaid 1.28 (1.02–1.59) This may be due to only weight and not height being measured during
Other 0.83 (0.63–1.08) an encounter because the height for established and adult patients is as-
Use an electronic medical record system
No 1.00 [reference]
sumed to be the same at each visit. However, in most electronic health
Yes, part paper part electronic 1.75 (1.28–2.41) records, an updated BMI cannot be calculated without both a weight
Yes, all electronic 1.58 (1.25–2.00) and height entered at each visit even if the height has not changed. It
Patient seen before? should be noted that weight was measured at 87% or more visits across
No 1.00 [reference]
the survey years, so the percent of visits with BMI screening would be
Yes 0.83 (0.71–0.97)
Region higher if height did not need to be entered to update BMI. There is a
Northeast 0.92 (0.61–1.37) need for more built in sophisticated clinical decision support tools with-
Midwest 1.00 (0.70–1.44) in the electronic medical record that can automatically extract previous
South 1.21 (0.83–1.75) vital sign data such as last recorded height and include it in calculations
West 1.00 [reference]
of BMI once a new weight has been entered during an encounter. This
 S.L. Fitzpatrick, V.J. Stevens / Preventive Medicine 99 (2017) 128–133 131

Fig. 1. Weighted percentage of patient visits with obesity diagnosis, diet/nutrition education, exercise education, weight reduction education, and any weight-related education by survey
year among visits with patients with body mass index ≥ 30. aAdjusted for age, sex, race/ethnicity, insurance type, risks for obesity-related diseases or mortality, if the patient had been seen
before, presence of electronic medical record, and practice region. bPercent of visits with any weight-related education in 2012–2013 was significantly lower than the percent in 2008–
2009 (OR = 0.62, 95% CI 0.41–0.92).

improvement may decrease burden on physicians or medical staff and
perhaps increase screening and diagnosis.
Across the survey years, 70% or more of patients with obesity did not
have a documented obesity diagnosis. Although electronic medical re-
cords facilitate the input of vital signs, documentation of an obesity
diagnosis requires the provider to take additional steps. To diagnose
obesity, physicians would need to add obesity to the patient's problem
list. However, there is no real incentive for physicians to diagnose
Table 4
Predictors of any weight-related education, 2008–2013.

Table 3 Adjusted OR (95% CI)

Predictors of obesity diagnosis, 2008–2013. Survey years
2008–2009 1.00 [reference]
Adjusted OR (95% CI)
2010–2011 0.94 (0.69–1.28)
Survey years 2012–2013 0.62 (0.41–0.92)
2008–2009 1.00 [reference] Age group, y
2010–2011 1.08 (0.90–1.29) 18–44 0.99 (0.77–1.27)
2012–2013 1.11 (0.86–1.45) 45–64 1.09 (0.89–1.33)
Age group, y 65 and up 1.00 [reference]
18–44 2.34 (1.86–2.94) Sex
45–64 1.87 (1.56–2.24) Female 0.94 (0.82–1.07)
65 and up 1.00 [reference] Male 1.00 [reference]
Sex Race/ethnicity
Female 1.41 (1.29–1.53) White non-Hispanic 1.00 [reference]
Male 1.00 [reference] Black non-Hispanic 1.47 (1.06–2.03)
Race/ethnicity Hispanic 1.39 (1.08–1.79)
White non-Hispanic 1.00 [reference] Other 1.62 (1.08–2.43)
Black non-Hispanic 1.47 (1.21–1.79) Risks for obesity-related disease/mortality
Hispanic 1.14 (0.94–1.39) Low 1.00 [reference]
Other 0.55 (0.42–0.71) Moderate 1.30 (1.02–1.65)
Risks for obesity-related disease/mortality High 1.69 (1.28–2.22)
Low 1.00 [reference] Insurance
Moderate 1.91 (1.62–2.26) Private 1.00 [reference]
High 4.76 (3.97–5.70) Medicare 0.78 (0.63–0.98)
Insurance Medicaid 0.97 (0.68–1.37)
Private 1.00 [reference] Other 1.24 (0.77–2.00)
Medicare 0.93 (0.77–1.11) Obesity diagnosis
Medicaid 1.23 (1.04–1.46) No 1.00 [reference]
Other 1.22 (0.85–1.74) Yes 3.37 (2.88–3.95)
Use an electronic medical record system Use an electronic medical record system
No 1.00 [reference] No 1.00 [reference]
Yes, part paper part electronic 1.12 (0.92–1.38) Yes, part paper part electronic 1.00 (0.70–1.44)
Yes, all electronic 1.10 (0.94–1.29) Yes, all electronic 1.00 (0.79–1.28)
Patient seen before? Patient seen before?
No 1.00 [reference] No 1.00 [reference]
Yes 1.30 (1.12–1.52) Yes 1.04 (0.81–1.32)
Region Region
Northeast 1.35 (1.00–1.82) Northeast 0.82 (0.51–1.30)
Midwest 1.26 (0.98–1.62) Midwest 0.69 (0.47–1.03)
South 1.03 (0.80–1.33) South 0.60 (0.39–0.94)
West 1.00 [reference] West 1.00 [reference]
132 S.L. Fitzpatrick, V.J. Stevens / Preventive Medicine 99 (2017) 128–133
obesity since it is still not considered a billable medical condition by
most insurance companies, with the exception of Medicare. Despite
the overall low rate of diagnosed obesity, patients who were female,
18–64 years of age, Black non-Hispanic, Medicaid, established patient,
or at moderate or high risk for obesity-related disease complications
were more likely to have a diagnosis. Previous survey based studies
have indicated that women as well as young and middle-aged adults
are more likely to have an obesity diagnosis, perhaps because members
of these populations are more likely to discuss concerns about their
weight with their physician that prompted an obesity diagnosis at the
end of the visit (Ahmed et al., 2016). Patients at high risk for obesity-re-
lated disease complications and mortality perhaps prompt physicians to
regularly monitor their BMI and address progress with lifestyle changes
and weight loss in order to prevent CVD events. Similarly, patients from
racial/ethnic minority backgrounds or with Medicaid may also be more
likely to be at high risk for obesity-related diseases and more frequent
users of care (Savageau et al., 2006); thus maybe increasing the likeli-
hood of receiving an obesity diagnosis and some health education.
Given the findings in Kraschnewski et al. (2013), the percent of pri-
mary care visits with weight management counseling continued to sig-
nificantly decline by 12 percentage points between 2008–2009 and
2012–2013, despite national recommendation and policies established
during this time period. As previously mentioned, there is no immediate
financial incentive to address and manage obesity in the primary care
office for adult patients 18–64 years old (Kushner and Sarwer, 2011).
Although, Medicare reimburses intensive behavioral therapy for obesity
for their beneficiaries (DHHS Centers for Medicare and Medicaid
Services, 2012), the occurrence of weight management counseling dur-
ing a visit also decreased among this patient population. Most physi-
cians are unaware of this reimbursement policy or how to effectively
implement it without disrupting current clinical workflow given the
number of visits that must occur (i.e., 22 total). Additional physician
specific barriers to providing weight management counseling include
time constraints, discomfort with discussing weight issues, lack of train-
ing in weight management, and lack of knowledge regarding available
treatments (Bleich et al., 2012a; Bleich et al., 2012b; Kolasa and
Rickett, 2010; Kushner, 1995). Patients with an obesity diagnosis were
three times more likely to receive weight management counseling
than those without a diagnosis. Visits that did include weight manage-
ment counseling were about 20 min in duration, which is consistent
with the expected length of an intensive behavioral therapy session
using the CMS model (i.e., 10–15 min) (DHHS Centers for Medicare
and Medicaid Services, 2012). However, based on 2005–2006 NAMCS
data, only 8% (i.e., ~1.6 min) of the 20 min visit was actually spent ad-
dressing obesity (Tsai et al., 2011). Thus, even if weight management
counseling is indicated in the medical chart that does not guarantee
that a sufficient amount of time is spent providing high quality
counseling.
4.1. Limitations
There are several limitations in this study. First, the NAMCS data is a
cross-sectional survey based on only one random week of clinic visits
per physician over a year. Thus, diagnosis of obesity and weight man-
agement counseling could have occurred during another encounter
not included in the survey sample. Second, the focus on primary care
visits as the unit of analysis, may have resulted in oversampling of sicker
patients or frequent users of primary care. Third, since the CMS Elec-
tronic Medical Record Meaningful Use Incentive Program was not fully
implemented until 2011 (Centers for Medicare and Medicaid Services,
2014), perhaps not enough time has passed to see the impact of finan-
cial incentives on obesity management in primary care. Fourth, there
was a change in the sampling design and methodology for the 2012–
2013 NAMCS (National Center for Health Statistics, 2016b). Specifically,
community health center visits were excluded, Census Bureau repre-
sentatives were more likely to complete the survey forms than
physicians and clinic staff, and the survey was completed using a com-
puterized form instead of a paper form. Increased use of the Census Bu-
reau representatives and computerized forms may explain the
increased number of visits sampled in 2012–2013. However, it is not
clear if it was these changes or actual practice patterns that impacted
the increase or decrease in documentation of obesity-related metrics
(National Center for Health Statistics, 2016b).
5. Conclusions
Despite emerging national recommendations and policies since
2008, obesity management in primary care is still suboptimal. A recent
study indicated that a majority of patients want to discuss weight loss
with their physician (Sherson et al., 2014). Thus, there is a need for pri-
mary care delivery redesign to facilitate rather than hinder physicians
addressing obesity with their patients. Part of this redesign is increasing
physician skills in starting the conversation to sensitively address obesi-
ty with a patient (Stop Obesity Alliance, 2014). It is not realistic to ex-
pect primary care physicians to deliver intensive behavioral weight
loss counseling to all of their patients with obesity. Thus, the process
of ordering referrals and coverage of obesity management specialist
(e.g., registered dietitians, psychologists) and community-based pro-
grams should be made easier in order to increase referral options for
physicians and access to care for patients (Fitzpatrick et al., 2016). In ad-
dition, the electronic medical record is emerging as a tool to not only fa-
cilitate BMI screening, but could also be used to facilitate weight
management counseling during an encounter (Bordowitz et al., 2007;
Tang et al., 2012). Given the obesity epidemic and increased risk for
chronic diseases, identifying practical strategies to enforce policies and
implement evidence-based treatment services in primary care should
be a high priority in healthcare reform.
Conflicts of interest
The authors have no conflicts of interest to disclose.
References
Ahmed, N.U., Delgado, M., Saxena, A., 2016. Trends and disparities in the prevalence of
physicians' counseling on diet and nutrition among the U.S. adult population,
2000–2011. Prev. Med. 89, 70–75.
Alexander, S.C., Cox, M.E., Boling Turer, C.L., et al., 2011. Do the five A's work when phy-
sicians counsel about weight loss? Fam. Med. 43 (3), 179–184.
Bleich, S.N., Bennett, W.L., Gudzune, K.A., Cooper, L.A., 2012a. National survey of US pri-
mary care physicians' perspectives about causes of obesity and solutions to improve
care. BMJ Open 2 (6). http://dx.doi.org/10.1136/bmjopen-2012-001871 (Print
002012).
Bleich, S.N., Bennett, W.L., Gudzune, K.A., Cooper, L.A., 2012b. Impact of physician BMI on
obesity care and beliefs. Obesity (Silver Spring, Md.) 20 (5), 999–1005.
Bordowitz, R., Morland, K., Reich, D., 2007. The use of an electronic medical record to im-
prove documentation and treatment of obesity. Fam. Med. 39 (4), 274–279.
Butryn, M.L., Webb, V., Wadden, T.A., 2011. Behavioral treatment of obesity. Psychiatr.
Clin. North Am. 34 (4), 841–859.
Centers for Medicare and Medicaid Services. EHR Incentive Programs. (Vol) 2013.
Centers for Medicare and Medicaid Services, 2014. EHR Incentive Programs. (Vol).
DHHS Centers for Medicare and Medicaid Services, 2012. Intensive behavioral therapy
(IBT) for obesity. Medicare Learning Network.
Fitzpatrick, S.L., Wischenka, D., Appelhans, B.M., et al., 2016. An evidence-based guide for
obesity treatment in primary care. Am. J. Med. 129 (1), 115 (e1-7).
Flegal, K.M., Carroll, M.D., Kit, B.K., Ogden, C.L., 2012. Prevalence of obesity and trends in
the distribution of body mass index among US adults, 1999–2010. JAMA 307 (5),
491–497.
Jensen, M.D., Ryan, D.H., Apovian, C.M., et al., 2013. AHA/ACC/TOS guideline for the man-
agement of overweight and obesity in adults: a report of the American College of Car-
diology/American Heart Association Task Force on Practice Guidelines and The
Obesity Society. J. Am. Coll. Cardiol. 2013.
Kolasa, K.M., Rickett, K., 2010. Barriers to providing nutrition counseling cited by physi-
cians: a survey of primary care practitioners. Nutr. Clin. Pract. 25 (5), 502–509.
Kraschnewski, J.L., Sciamanna, C.N., Stuckey, H.L., et al., 2013. A silent response to the obe-
sity epidemic: decline in US physician weight counseling. Med. Care 51 (2), 186–192.
Kushner, R.F., 1995. Barriers to providing nutrition counseling by physicians: a survey of
primary care practitioners. Prev. Med. 24 (6), 546–552.
Kushner, R.F., Sarwer, D.B., 2011. Medical and behavioral evaluation of patients with obe-
sity. Psychiatr. Clin. North Am. 34 (4), 797–812.
 S.L. Fitzpatrick, V.J. Stevens / Preventive Medicine 99 (2017) 128–133
Ma, J., Xiao, L., Stafford, R.S., 2009. Adult obesity and office-based quality of care in the
United States. Obesity (Silver Spring, Md.) 17 (5), 1077–1085.
Moyer, V.A., 2012. Force USPST. Screening for and management of obesity in adults: U.S.
preventive services task force recommendation statement. Ann. Intern. Med. 157 (5),
373–378.
National Center for Health Statistics, 2016a. NAMCS/NHAMCS Ambulatory Health Care
Data. (Vol).
National Center for Health Statistics, 2016b. NAMCS/NHAMCS Questionnaires, Datasets, &
Related Documentation. (Vol).
Ogden, C.L., Carroll, M.D., Kit, B.K., Flegal, K.M., 2014. Prevalence of childhood and adult
obesity in the United States, 2011–2012. JAMA 311 (8), 806–814.
Savageau, J.A., McLoughlin, M., Ursan, A., Bai, Y., Collins, M., Cashman, S.B., 2006. Charac-
teristics of frequent attenders at a community health center. J. Am. Board Fam. Med.
19 (3), 265–275.
Sherson, E.A., Yakes Jimenez, E., Katalanos, N., 2014. A review of the use of the 5 A's model
for weight loss counselling: differences between physician practice and patient de-
mand. Fam. Pract. 31 (4), 389–398.
133
Stop Obesity Alliance, 2014. Why Weight? A Guide to Discussing Obesity & Health With
Your Patients. (Vol).
Tang, J.W., Kushner, R.F., Cameron, K.A., Hicks, B., Cooper, A.J., Baker, D.W., 2012. Electron-
ic tools to assist with identification and counseling for overweight patients: a ran-
domized controlled trial. J. Gen. Intern. Med. 27 (8), 933–939.
Tsai, A.G., Abbo, E.D., Ogden, L.G., 2011. The time burden of overweight and obesity in pri-
mary care. BMC Health Serv. Res. 11 (191-6963-6911-6191).
Vallis, M., Piccinini-Vallis, H., Sharma, A.M., Freedhoff, Y., 2013. Clinical review: modified 5
As: minimal intervention for obesity counseling in primary care. Can. Fam. Physician
59 (1), 27–31.
Wadden, T.A., Webb, V.L., Moran, C.H., Bailer, B.A., 2012. Lifestyle modification for obesity:
new developments in diet, physical activity, and behavior therapy. Circulation 125
(9), 1157–1170.