We searched PubMed, Scopus, and Google Scholar for peer-reviewed journal articles, using search terms including: obesity treatment in primary care, obesity diagnosis, barriers
to obesity treatment, obesity bias in primary care, obesity discussion tools, motivational interviewing
techniques, and physician training in obesity.
We additionally reviewed relevant public sources, including the National Center for Health Statistics, the Yale Rudd Center for Food Policy and Obesity, and previously published research conducted by STOP Obesity Alliance.
Most providers are not having instructive or satisfactory conversations with their patients about weight. Even when physicians have conversations about weight, patients do not necessarily come away from the experience with the information they need.
Why primary care? Primary care providers are an important source of information and
guidance on health-related issues. Primary care physicians are uniquely situated to
help address overweight and obesity.
- Physician offices host over one billion patient visits each year, with visits to
primary care physicians (PCPs) encompassing 56 percent of doctor visits.1
- A person will visit his or her PCP an average of 1.8 times per year, providing
these physicians with an excellent opportunity to regularly interact with a wide
variety of patients.2
- In 2012, 28 percent of primary care patients were overweight, and 35 percent
were obese.3 Taken together, 63 percent of patients seen by a PCP have an
- Physicians feel a responsibility to treat weight. In 2009, the STOP Obesity
Alliance conducted a survey of 290 primary care physicians, assessing treatment
of patients with overweight and obesity.4 The survey found that 89 percent of
physicians agreed it was their responsibility to help a person with overweight
Physicians are not diagnosing overweight and obesity in their patients.
- The National Health and Nutrition Examination Survey (NHANES), a cross-sectional
nationally representative study, found that only 45 percent of patients
with a BMI greater than 25 were told by a physician that they were
overweight.5 For those with a BMI over 30, 66 percent received an obesity
- According to a study of 9,827 Mayo Clinic patients, 2,543 had a BMI indicating
obesity, yet only 20 percent of these patients with obesity received an obesity
diagnosis.6 The study also found that diagnosis was the strongest predictor in
formulation of a weight management plan. Approximately 40 percent of
patients who received an obesity diagnosis also received a treatment plan, while
only 20 percent of patients with obesity that was undiagnosed received a
Studies have shown that when physicians have weight-related discussions with their
patients, the patients are able to recall the conversation with excellent accuracy and
will increase their weight-loss efforts.
- In a meta-analysis of 32 reports, all except one demonstrated a positive effect of
PCP advice on patient engagement in weight-loss efforts.8
- One study compared physician and patient reports of weight discussions with
audio recordings of patient visits. Overall, physicians were 70 percent accurate
in correctly recalling conversations they had with patients, while 67 percent of
patients correctly summarized the visit.9 However, for discussions of weight
only, these percentages increased greatly. Physicians had 97 percent accuracy
and patients had 98 percent accuracy with congruence between the two groups
of 95 percent.
Physicians who are struggling to discuss weight with their patients currently lack
the necessary resources (most notably training, patient materials, and time) to treat patients
with overweight and obesity.
PCPs have reported several common barriers to discussing and treating obesity.
- Physicians cite time limitations, as well as avoiding referrals to services not
covered by insurance, as reasons for avoiding weight counseling.10
- In 2007, a focus group of 22 physicians representing internal medicine, family
medicine, ob/gyn, and pediatrics, as well as four nurse practitioners, detailed
the barriers they encounter in trying to treat obesity.11 Concerned by the lack of
reimbursement for time spent on preventive procedures, physicians cited
payment as the number one barrier to obesity treatment. Next were time
constraints, followed by legal issues, inconsistency between guidelines and
available resources, and concern that discussions regarding weight might be
offensive or be perceived as “lecturing.” The focus group also discussed
facilitators in obesity treatment, specifically mentioning patient materials like
pamphlets and handouts, as well as “tool consistency,” with listed user-friendly
resources and implementation of guidelines as examples.12
Training physicians to counsel patients can produce measurable patient outcomes;
however, most PCPs lack training in treatment of overweight and obesity.
- Half of the 23 residents in the New York University School of Medicine Primary
Care Residency Program received a five hour obesity training curriculum based
on the 5As model (assess, advise, agree, assist, and arrange). More than 15
percent of patients whose resident had specific training in obesity saw
statistically significant weight loss. While this is not a particularly high
percentage, only 5 percent of patients whose resident did not undergo obesity
training saw the same weight loss results.13
- A 2003 survey of 87 internal medicine residents found that 60 percent did not
know the minimum BMI for diagnosing obesity, 69 percent did not recognize
waist circumference as a reasonable measure of overweight/obesity, 39 percent
incorrectly reported their own BMI, and only 44 percent felt qualified to treat
patients with obesity.14
- Similar results were seen with physicians in 2008. In a study observing
competency in obesity treatment among internal medicine, pediatric, and
psychiatric physicians, 48 percent could not adequately answer patient
questions about obesity treatments and 39 percent could not adequately
- A STOP survey of 290 physicians representing general, family, and internal
medicine found that 72 percent of those polled said no one in their practice had
been trained to deal with obesity diagnosis and management.16 The sample of
responses was weighted to be representative of the PCP population in the U.S.
by using gender, number of years in practice, and regional demographics from
the American Medical Association Masterfile.
- There is confusion among physicians regarding their ability to treat obesity. In
2012, a group of 500 PCPs polled were split nearly down the middle, with 48
percent responding that dietitians and nutritionists were more qualified to help
patients with obesity, while 41 percent believed physicians were the most
qualified to help.17 Smaller percentages left the responsibility to
endocrinologists, psychologists, and nurses. Interestingly, when asked about
their abilities to treat obesity, 90 percent reported feeling confident in their
weight counseling abilities, but only 44 percent reported success in helping their
patients with obesity lose weight.18
Behavioral and medical treatment can be effective in certain patient populations, but improvised discussions run the risk of potentially stigmatizing or shaming patients, which can be detrimental to obesity treatment and patient outcomes.
Several studies have demonstrated a lack of respect that some physicians have for
patients with obesity.
- In a study of 40 physicians, higher BMI had a significant and negative correlation with
respect; physicians reported “low respect” for 39 percent of their patients with
overweight and obesity.19
- In another study, 126 individuals with overweight and obesity admitted to feeling
judged because of their weight.20 Of these, only 14 percent achieved significant
weight loss, compared to 20 percent of individuals with overweight and obesity who
reportedly did not feel judged because of their weight. Patients who felt judged by
their PCP were more likely to attempt weight loss, but were not more likely to achieve
clinically significant results. Unintentionally stigmatizing patients could negate
otherwise effective treatment.
- Lack of respect for patients with obesity can be seen as early as the post-graduate
level. A group of 107 post-graduate students across several health disciplines,
including physician assistants and medical residents, were asked questions about their
attitudes toward patients with obesity.21 Weight bias was evident, with 65 percent of
students reporting their patients with obesity were a target of negative attitudes by
- Three key themes emerged in qualitative interviews among individuals living with
obesity, health professionals, and policy makers22.
Blame as a devastating relation of power
Participants with obesity shared feelings of self-blame, shame and embarrassment, discussing their frustrations with failed attempts to lose weight and the absence of support. Health care providers viewed
a lack of weight loss as an unwillingness to commit, voicing their
disappointment in patients who are unable to lose weight. They also
blamed themselves, describing feelings of powerlessness and inability
to support or provide follow up.
Tensions in management
Both patients and health care providers described a lack of support
from the health care system, and health providers in particular
detailed the struggle to approach obesity management. Policy makers
discussed the trend of shifting the focus from obesity to underlying
issues like nutrition and physical activity, which means treatment is
often overlooked in favor of prevention policies. If the physicians do
not feel equipped to treat obesity and the system perpetuates a lack
of interest in treatment, individuals are left alone to struggle with
Prevailing conflicts in medical management discourse
Physicians are less likely to treat obesity alone; rather they work with
patients living with both obesity as well as another diagnosed chronic
health condition, indicating reluctance to accept obesity as a disease.
Policy makers were hesitant to conceptualize obesity within a medical
model, questioning whether medical treatment was necessary.
Several policy makers suggest community health promotion was a
better avenue to address obesity, referring to it as a “risk factor”
rather than a “disease.”
- Clear understanding of public preference and perception of weight terminology is
crucial to creating an encouraging and informative weight counseling program.
Physician wording can impact treatment, by either motivating or harming patient-physician
A study of 1,064 participants, 62 percent of whom had overweight or
obesity, asked which weight-related words participants found
motivating and which they found stigmatizing.23 Desirable weight-related
words were: weight, unhealthy weight, and overweight.
Undesirable words were: morbidly obese, obese, and fat. These
“blaming” words were so undesirable that 19 percent of patients said
they would avoid future medical visits if this language was used
consistently, and 21 percent said they would seek new doctors if they
While starting the discussion is important, utilizing specific communication techniques
can provide a more effective approach to weight-related conversations.
- A 2010 study analyzed 137 patient surveys following a PCP visit.24 The surveys
assessed the physicians’ use of the 5As model (assess, advise, agree, assist, and
arrange). Patients with higher levels of motivation reported receiving more 5As
counseling than those with less motivation. Each additional counseling session
was associated with higher odds of the patient being motivated to lose weight.
On average, most of the 5As were employed less than once per visit, with a
particular focus on assess over assist or arrange. Patient-centered approaches—
responsiveness to individual needs, goals, and preferences—were also positively
associated with intentions to eat better and exercise.
- In an observational study of 461 patients with overweight or obesity, physicians’
use of interviewing techniques were coded from audio recordings of patient
interactions and then compared to subsequent patient weight loss.25 In general,
motivational interviewing (MI) techniques are:
Although weight discussions did not necessarily lead to weight loss, the use of
MI did successfully predict weight loss. Simply having the conversation is not
enough to encourage patients to lose weight. How these conversations are
conducted seems to be a much more powerful indicator of subsequent weight
loss. Unfortunately, fewer than half of the observed physicians reported
receiving training in behavioral counseling.26
- Designed to motivate the ambivalent
- Collaborative in nature
- Understanding of the patient perspective
- Accepting of patient motivation or lack of motivat'on
- Meant to assist patients in finding their own solutions to their
problems, thereby discovering their own motivation
- Affirming of a patient’s freedom to change
- Encouraging of “change statements”
- Not judging, confronting, or providing advice without
- A separate study compared weight-loss efforts of 55 participants with obesity,
half of whom engaged in a behavioral weight-loss program and half of whom
engaged in the same behavioral program as well as MI sessions.27 Both groups
attended weekly, small-group sessions for 20 weeks. The program encouraged
gradual weight loss, progressively increasing physical activity, and decreased fat
intake. Those in the MI group also attended a weekly session with a clinical
psychologist who was trained in motivational interviewing techniques. Those in
the MI group lost significantly more weight than the behavioral weight loss
group alone and also engaged in significantly more planned physical activity
- Finally, a study observing women with overweight and obesity saw that those
receiving MI in addition to a regular behavioral program attended significantly
more sessions and turned in more food diaries than the standard group.28 While
no significant weight loss differences were seen between the two groups, the
results suggest MI enhances adherence to treatment and recommendations.
Some researchers have developed tools designed to provide assistance to PCPs
treating obesity. Though few, these real world applications have been shown to effectively
educate patients through informed conversations with their physicians, while simultaneously
removing or lessening other barriers to obesity treatment.
The best way to ensure physicians are employing positive communication methods is
to provide them with the necessary resources to discuss overweight and obesity.
- A simple electronic reminder can have a profound impact on rates of weight
counseling in pregnant women. In one study, the rate of counseling seen in
ob/gyn and family medicine practices increased from 3 percent to 51 percent
after an intervention that utilized a pre-set alert was added to the Electronic
Medical Record (EMR) system.29 When a patient’s BMI indicated obesity, a popup
window appeared on the computer screen with a counseling reminder and a
detailed, interdisciplinary script. Before the alert was added to the electronic
system, only 4 percent of patients had determined a numerical weight goal with
her physician, compared to the 57 percent who discussed a concrete goal after
- The Vermont Department of Health, along with The University of Vermont
College of Medicine, created a primary care weight management tool kit.30 This
tool kit was tested in Wisconsin primary care clinics. The tool kit is essentially a
clinic algorithm to guide visits. It also includes education on MI techniques for
PCPs. Providers found the tool kit helpful, straightforward, and easy to use,
while 98 percent of patients with a BMI over 25 found the conversations
generated by the tool kit to be useful. In fact, 90 percent agreed they had
received information they felt would help them meet their weight loss goals.
Nearly 70 percent of physicians reported that the nursing staff should be trained
in the tool kit as well. Unfortunately, a majority of the physicians found the tool
kit to be excessively time consuming.