Can physicians accurately predict which patients will lose weight, improve nutrition and increase physical activity?

BACKGROUND: Physician counselling may help patients increase physical activity, improve nutrition and lose weight. However, physicians have low outcome expectations that patients will change. The aims are to describe the accuracy of physicians' outcome expectations about whether patients will follow weight loss, nutrition and physical activity recommendations. The relationships between physician outcome expectations and patient motivation and confidence also are assessed. METHODS: This was an observational study that audio recorded encounters between 40 primary care physicians and 461 of their overweight or obese patients. We surveyed physicians to assess outcome expectations that patients will lose weight, improve nutrition and increase physical activity after counselling. We assessed actual patient change in behaviours from baseline to 3 months after the encounter and changes in motivation and confidence from baseline to immediately post-encounter. RESULTS: Right after the visit, ~55% of the time physicians were optimistic that their individual patients would improve. Physicians were not very accurate about which patients actually would improve weight, nutrition and physical activity. More patients had higher confidence to lose weight when physicians thought that patients would be likely to follow their weight loss recommendations. CONCLUSIONS: Physicians are moderately optimistic that patients will follow their weight loss, nutrition and physical activity recommendations. Patients might perceive physicians' confidence in them and thus feel more confident themselves. Physicians, however, are not very accurate in predicting which patients will or will not change behaviours. Their optimism, although helpful for patient confidence, might make physicians less receptive to learning effective counselling techniques.

Correlates of sedentary time and physical activity among preschool-aged children.

INTRODUCTION: Few studies have examined the correlates of objectively measured amounts of sedentary time and physical activity in young children. We evaluated the demographic, biological, behavioral, social, and environmental correlates of the amount of sedentary time and moderate-to-vigorous physical activity (MVPA) as measured by accelerometry in preschool-aged children. METHODS: We obtained baseline measurements of physical activity by using an Actical accelerometer among 337 preschool-aged children (aged 2-5) of overweight or obese mothers. For children, we defined sedentary time as less than 12 counts per 15 seconds and MVPA as 715 or more counts per 15 seconds. Body mass index of the mother and child (calculated from measured height and weight) and maternal physical activity as measured by accelerometer were included as potential correlates. Mothers self-reported all other potential correlates. We used multivariable linear regression analyses to examine correlates of the amount of sedentary time and MVPA. RESULTS: Children had an average of 6.1 hours per day of sedentary time and 14.9 minutes per day of MVPA. In multivariable analysis, boys (P <.001) had fewer minutes per day of sedentary time, whereas older children (P <.001), boys (P <.001), children in high-income households (>$60,000/y [P = .005]), and children who spent more time outdoors (P = .001) had more MVPA. CONCLUSION: Both modifiable and nonmodifiable factors were correlated with preschool children's amount of MVPA, which can be helpful when designing interventions for this age group. The lack of correlates for sedentary time indicates the need for further investigation into this behavior.

Predictors of weight loss communication in primary care encounters.

OBJECTIVE: Evidence suggests that physicians' use of motivational interviewing (MI) techniques helps patients lose weight. We assessed patient, physician, relationship, and systems predictors of length of weight-loss discussions and whether physicians' used MI techniques. METHODS: Forty primary care physicians and 461 of their overweight or obese patients were audio recorded and surveyed. RESULTS: Weight-related topics were commonly discussed (nutrition 78%, physical activity 82%, and BMI/weight 72%). Use of MI techniques was low. A multivariable linear mixed model was fit to time spent discussing weight, adjusting for patient clustering within physician. More time was spent with obese patients (p=.0002), by African American physicians (p=.03), family physicians (p=.02), and physicians who believed patients were embarrassed to discuss weight (p=.05). Female physicians were more likely to use MI techniques (p=.02); African American physicians were more likely to use MI-inconsistent techniques (p<.001). CONCLUSION: Primary care physicians routinely counsel about weight and are likely to spend more time with obese than with overweight patients. Internists spend less time on weight. Patient and systems factors do not seem to influence physicians' use MI techniques. PRACTICE IMPLICATIONS: All physicians, particularly, male and African American physicians, could increase their use of MI techniques to promote more weight loss among patients.

Effects of counseling techniques on patients' weight-related attitudes and behaviors in a primary care clinic.

OBJECTIVE: Examine primary care physicians' use of counseling techniques when treating overweight and obese patients and the association with mediators of behavior change as well as change in nutrition, exercise, and weight loss attempts. METHODS: We audio recorded office encounters between 40 physicians and 461 patients. Encounters were coded for physician use of selected counseling techniques using the Motivational Interviewing Treatment Integrity (MITI) scale. Patient motivation and confidence as well as Fat and Fiber Diet score (1-4), Framingham physical activity questionnaire (MET-minutes), and weight loss attempts (yes/no) were assessed by surveys. Generalized linear models were fit, including physician, patient, and visit level covariates. RESULTS: Patients whose physicians were rated higher in empathy improved their Fat and Fiber intake 0.18 units (95% CI 0, 0.4). When physicians used "MI consistent" techniques, patients reported higher confidence to improve nutrition (OR 2.57, 95% CI 1.2, 5.7). CONCLUSION: When physicians used counseling techniques consistent with MI principles, some of their patients' weight-related attitudes and behaviors improved. PRACTICE IMPLICATIONS: Physicians may not be able to employ formal MI during a clinic visit. However, use of counseling techniques consistent with MI principles, such as expression of empathy, may improve patients' weight-related attitudes and behaviors.

Physician communication techniques and weight loss in adults: Project CHAT.

BACKGROUND: Physicians are encouraged to counsel overweight and obese patients to lose weight. PURPOSE: It was examined whether discussing weight and use of motivational interviewing techniques (e.g., collaborating, reflective listening) while discussing weight predicted weight loss 3 months after the encounter. METHODS: Forty primary care physicians and 461 of their overweight or obese patient visits were audio recorded between December 2006 and June 2008. Patient actual weight at the encounter and 3 months after the encounter (n=426); whether weight was discussed; physicians' use of motivational interviewing techniques; and patient, physician, and visit covariates (e.g., race, age, specialty) were assessed. This was an observational study and data were analyzed in April 2009. RESULTS: No differences in weight loss were found between patients whose physicians discussed weight or did not. Patients whose physicians used motivational interviewing-consistent techniques during weight-related discussions lost weight 3 months post-encounter; those whose physician used motivational interviewing-inconsistent techniques gained or maintained weight. The estimated difference in weight change between patients whose physician had a higher global motivational interviewing-Spirit score (e.g., collaborated with patient) and those whose physician had a lower score was 1.6 kg (95% CI=-2.9, -0.3, p=0.02). The same was true for patients whose physician used reflective statements: 0.9 kg (95% CI=-1.8, -0.1, p=0.03). Similarly, patients whose physicians expressed only motivational interviewing-consistent behaviors had a difference in weight change of 1.1 kg (95% CI=-2.3, 0.1, p=0.07) compared to those whose physician expressed only motivational interviewing-inconsistent behaviors (e.g., judging, confronting). CONCLUSIONS: In this observational study, use of motivational interviewing techniques during weight loss discussions predicted patient weight loss.

Nicotine replacement and behavioral therapy for smoking cessation in pregnancy.

BACKGROUND: This study examines whether adding nicotine replacement therapy (NRT) to cognitive-behavioral therapy (CBT) for pregnant smokers increases rates of smoking cessation. METHODS: An open-label randomized trial (Baby Steps, n=181) of CBT-only versus CBT+NRT (choice of patch, gum, or lozenge; 1:2 randomization) was used. Data were collected from 2003 through 2005; analyses were conducted in 2006 and 2007. Outcomes were biochemically validated self-reported smoking status at 7 weeks post-randomization, 38 weeks gestation, and 3 months postpartum. RESULTS: Women in the CBT+NRT arm were almost three times more likely than women in the CBT-only arm to have biochemically validated cessation at both pregnancy time points (after 7 weeks: 24% vs 8%, p=0.02; at 38 weeks gestation: 18% vs 7%, p=0.04), but not at 3 months postpartum (20% vs 14%, p=0.55). Recruitment was suspended early by an Independent Data and Safety Monitoring Board when an interim analysis found a higher rate of negative birth outcomes in the CBT+NRT arm than in the CBT-only arm. In the final analysis, the difference between the arms in rate of negative birth outcomes was 0.09 (p=0.26), when adjusted for previous history of preterm birth. CONCLUSIONS: The addition of NRT to CBT promoted smoking cessation in pregnant women. This effect did not persist postpartum. More data are needed to determine safety parameters and to confirm the efficacy of NRT use during pregnancy.

Physicians' beliefs about discussing obesity: results from focus groups.

PURPOSE: Physicians are expected to discuss weight loss with overweight and obese patients. Physicians' beliefs, outcome expectancies, and strategies for addressing weight with patients have not been examined. DESIGN: Two focus groups of family physicians and internists included questions about obesity and how physicians discuss weight loss with patients. SETTING/SUBJECTS: Family physicians (n = 11) and internists (n = 6) from Duke University Medical Center's Department of Community and Family Medicine and Department of Medicine. ANALYSIS: Qualitative analysis approach using grounded theory methodology. RESULTS: Physicians' responses centered on five key themes: (1) responsibility, (2) barriers, (3) target populations, (4) introducing topic, and (5) ways to talk about obesity. CONCLUSION: Physicians have many barriers related to discussing weight loss with patients. Given the obesity epidemic, the need to understand how to have these discussions, when to have these discussions, and with whom to have these discussions becomes paramount to providing effective care for patients with obesity. Limited physician training in weight-loss counseling explains why physicians find it challenging to discuss obesity with patients.