The Journal for Nurse Practitioners
Volume 5, Issue 3 , Pages 161-167, March 2009

Barriers to Weight Loss Counseling

  • Jedediah S. Briscoe

      Affiliations

    • Jedediah Stevens Briscoe, MS, FNP, is a nurse practitioner for Promise Hospital in Salt Lake City, UT
    • ,
  • Judith A. Berry

      Affiliations

    • Judith A. Berry, PhD, APRN, FNP-BC, ANP-BC, is an associate professor and co-coordinator of the family nurse practitioner program at Brigham Young University.

Article Outline

Abstract 

Obesity is becoming a major problem affecting health and health care in the United States. While counseling patients on weight loss is effective, it is infrequently done. Lack of time, training, confidence, and reimbursement are some of the identified barriers to weight loss counseling. More research is needed, looking at these and other barriers, specifically, as they relate to nurse practitioners (NPs). This article looks at barriers to obesity counseling and how NPs can improve weight loss counseling.

Keywords:  barriers , counseling , nurse practitioner , obesity , weight loss

 

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Introduction 

Obesity is an increasing problem in the United States and more than 65% of the adult population is either overweight or obese.1 The increase in obesity has been an issue of national concern in recent years; however, it is not clear why the prevalence of obesity continues to rise.2 The obesity epidemic has been linked with many health problems. The Centers for Disease Control and Prevention (CDC) states that obese individuals are at an increased risk for hypertension, dyslipidemia, diabetes, coronary heart disease, stroke, gallbladder disease, osteoarthritis, sleep apnea, and other respiratory problems.3 The CDC has also found that some cancers, including endometrial, breast, and colon cancer, have a high correlation to obesity.3

In addition to the adverse health effects associated with obesity, studies have found that obesity accounts for 5% to 7% of national health expenditures in the United States. This amounts to an excess of $70 billion annually in health care costs.4 Another study found that the physical inactivity that accompanies obesity accounted for 23% of health plan charges and 27% of national health care charges.5 With the enormous costs both fiscally and physically, it is clear that the United States is facing a major problem.

Overweight is defined as a body mass index (BMI) of greater than 25.0 and obesity is defined as a BMI of greater than 30.0. The BMI is calculated as weight in kilograms divided by the square of height in meters and it is not gender specific.1 For the purpose of this article, the term obesity will include both overweight and obese categories.

There are a variety of treatment options to help people lose weight. Diet and exercise are the basis for successful weight loss.6, 7, 8 Some pharmacological treatments of obesity are available and have shown greater weight loss when used in conjunction with diet and lifestyle modification, as compared with diet and lifestyle modification alone.9, 10 There are also a number of surgical treatment options, which include restrictive procedures such as gastric bypass and malabsorptive procedures with biliopancreatic diversion.11, 12 Surgical treatments for obesity are effective in long-term weight loss but have many adverse effects. Thus, the benefits of weight loss must be assessed against the surgical risks.10 To sustain long-term weight loss, lifestyle modification is necessary.

Provider counseling, in conjunction with lifestyle modification, is effective for weight loss and reduction of risks associated with obesity.13, 14 The United States Preventive Service Task Force (USPSTF) found evidence was “fair to good” that intensive counseling with behavioral interventions led to sustained weight loss.15 Intensive counseling is defined as 2 or more counseling sessions in 1 month for at least the first 3 months of the intervention.16 Many studies have acknowledged the lack of weight loss counseling in the primary care setting.17, 18, 19, 20 The rate of counseling may increase when patients have comorbidities such as diabetes, but the overall rate is still low. One study found only 56% of overweight diabetics were counseled on weight loss.19

Both the American Academy of Nurse Practitioners (AANP) and the American College of Nurse Practitioners (ACNP) state that health promotion and disease prevention are part of the nurse practitioner's (NP's) role.21, 22 This places NPs in a situation to lead in the fight against obesity and the problems it poses. The purpose of this integrative literature review is to evaluate barriers to providing weight loss counseling for obese patients and to make clinical recommendations for NPs.

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Methods 

An electronic search was performed to identify studies from 2002 to 2007 in the following databases: CINAHL, Health Source: Nursing/Academic Edition, Medline, and Cochrane Database. Search terms used included obesity, overweight, weight loss, counseling, nurse practitioner, provider, physician, and barriers. The search was limited to research articles in English focusing on an adult population. To be included in this integrative literature review, articles had to address barriers to patient counseling regarding weight loss, deal with an obese or overweight adult patient population, and be based in primary care. Studies were excluded if they used pediatric or adolescent populations, focused on only male or female populations, included pharmacological therapy, or used surgical treatment for obesity. Four articles were found that met these criteria. The references from the articles were reviewed and an additional 2 articles were identified. These 2 studies, published before 2002, were included due to a lack of more recent research and because their findings were similar to current studies.23, 24 The last study was found through personal contact and was included because of its relevance to NPs.25 A total of 7 article were used for this literature review.

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Results 

Study Characteristics 

Providers. The majority of the populations studied were physicians (MDs).17, 23, 24, 26, 27, 28 A study of pharmacists was included because the identified barriers were similar to the studies of physicians and there was a limited amount of research on this subject.26 Another study also used several physician's assistants (PAs), who were included with the attending physicians in the results.28 Only one study was found that looked at NPs. The study looks at NPs' use of clinical preventive services (CPSs) and identifies barriers to their use in practice.25 This study was included because weight loss counseling was one of the CPSs used in the investigation of NPs. Additional provider characteristics from the studies are included in Table 1.

Table 1. Provider Characteristics
AuthornAge (years)GenderSpecialtyYears in Practice
Anderson1729-6165% femaleFamily practice internal medicineNot given
Berry5325-6481.1% femaleAdult and family NPs51% 1-5
26% 6-10
21% > 10
2% unknown
Forman55Not given63.6% male69.1% residents Iowa City VAMC cliniciansNot given
Hiddink633Mean age 4182% maleGeneral practitioners in Netherlands11 years
Huang2427-5278% maleFaculty and residents at LSUNot given
Kushner103044% < 4576% malePrimary care physiciansNot given
O'Donnell139Mean age 49.563% maleCommunity pharmacists in Texas24.3 years since initial licensure

Study methods. The studies' methods varied and included both focus group discussions and surveys. Aside from surveys and focus groups, no other methods were used to assess barriers to obesity counseling, probably because the subject does not lend itself well to a randomized controlled trial.

Five of the 7 studies used surveys to identify barriers. The study of NPs used a survey after analysis of taped patient-provider interactions.25 A study of physicians used a 47-item survey designed from prior studies and focus groups.28 A study in the Netherlands used a mailed survey sent to a random sample of general physicians.23 The study with the largest number of respondents (n = 1030) had a 49% response rate to a mailed survey. The survey used a 5-point Likert scale to indicate the degree of agreement with barriers.24 The last study to use a survey sent a random sample questionnaire to community pharmacists in Texas.26

The other 2 used focus groups for defining the barriers. Huang et al used 4 focus groups with 6 participants in each group and ranked barriers by the number of times they were mentioned.17 The other study used focus group sessions with a total of 17 participants; transcripts were then coded, themes were identified, and barriers were outlined as one of the themes.27

While 2 of the articles used focus groups as the primary research method, the rest developed surveys with at least some use of focus groups or transcript analysis in the development of the survey.17, 23, 24, 25, 27, 28 The only exception was the study of pharmacists, in which no discussion of the development of the survey was included.26

Barriers Identified 

The studies revealed a variety of barriers to weight loss counseling. The themes in the studies are outlined below in order of the number of studies that included each particular barrier (Table 2).

Table 2. Identified Barriers to Obesity Counseling
BarriersNo. of Articles
Lack of time6
Lack of training/education5
Scarce resources4
Lack of confidence in patients4
Poor reimbursement3
Vague guidelines2
Focusing on acute problem only1
Lack of patient demand/expectation1
Lack of privacy1

Lack of time. Six of the articles found lack of time to be a major barrier.17, 23, 24, 25, 26, 27 Kushner reported that 68% of surveyed providers spent 5 minutes or less on nutrition counseling.24 How much time is needed for weight loss counseling was not discussed in the articles. Overall, there was little discussion on the lack of time barrier in the studies, even though it was the most frequently mentioned barrier.

Lack of training or education. The next most common barrier to weight loss counseling was a lack of provider training or education. This lack of training, education, or knowledge barrier was indentified in 5 of the 7 articles.17, 23, 24, 27, 28 The studies showed that providers felt a lack of knowledge about nutrition, and that made discussing the issue with patients difficult. In addition, the studies found a lack of training in counseling techniques to be a barrier. Education and training was, therefore, lacking in both areas of communication, which included the topic of obesity and how to address it. The study of NPs reported a lack of provider knowledge along with the collaborating physician's scorn for guidelines as a barrier.25 Similar to the lack of training, a lack of confidence in the providers' ability to counsel patients was identified as a barrier in one of the articles.24

Lack of resources. Four articles identified a lack of resources as a barrier.17, 24, 25, 27 Resources included inadequate materials and a lack of comprehensive obesity management information. One article also expressed a lack of experience with dieticians, which may be another resource.17 Berry mentioned the shortage of office staff to be a resource barrier.25

Lack of confidence. Four studies reported that providers had a lack of confidence in patients' ability and motivation to lose weight.17, 23, 24, 27 This theme was expressed by providers as a general lack of belief in patients' motivation, pessimism about patients' ability or desire to lose weight, or low outcome expectancies. Kushner found a of lack of patient compliance with the obesity treatment and lack of patient motivation.24 Berry identified patient reticence to CPSs.25 Forman-Hoffman et al reported a belief that most patients were not ready to lose weight and a belief that there were few effective treatments for obesity, but also stated that providers thought weight loss counseling was beneficial.28

Lack of reimbursement. Another barrier identified in more than one article was the lack of reimbursement. Kushner found 61% of participants agreed or strongly agreed that lack of adequate reimbursement was a barrier, while 18% disagreed or strongly disagreed.24 O'Donnell reported that lack of reimbursement was in the top 3 barriers to weight loss counseling„ which also included lack of time and lack of patient demand.26 The study of NPs found reimbursement and patient finances to be the most common barrier to CPSs.25

Vague guidelines. Two studies found a barrier regarding the guidelines for obesity management. Alexander reported that vague guidelines for obesity management and prevention was a barrier associated with lack of training.27 In addition to vague guidelines, a few studies reported the collaborating MD's scorn for guidelines, and insufficient knowledge of best practice to be barriers.17, 25, 27

Other barriers. Another barrier identified in Berry's study, but not mentioned above, included the provider focusing only on the acute problem during a visit.25 Community pharmacists stated that a lack of patient demand or expectation for weight loss counseling and a lack of patient privacy were additional barriers.26

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Discussion 

Limitations 

The studies looked at barriers based on focus groups or surveys. While the surveys had larger numbers of providers, a survey may not provide the best means of finding barriers because the authors would have to identify barriers prior to interaction with the participants. Additionally, there was discussion of the development of the surveys in a majority of the studies but none provided discussion on the validity and reliability of the tools used.

The sample size of providers varied greatly among the studies, from 17 providers to 1030 providers. Two of the larger studies had a 63% response rate and a 49% response rate for surveys sent to over 1000 randomly selected providers.23, 24 A major concern with these 2 studies is that the information is more than a decade old. Excluding these 2 larger studies, the number of providers in the studies ranged from 17 to 55, with the exception of the pharmacist study, which had 139.17, 25, 26, 27, 28 The small sample size of these studies limits the generalizability of the data.

There are other factors that may affect the generalizability of the data. In addition to the small sample sizes and lack of randomization, several of the studies have very narrow population characteristics. An example is the study of community pharmacists in one area of Texas.26 Three other studies were done with convenience samples in a single community.17, 27, 28 Individually, these studies may not provide sufficient evidence to make recommendations for a practice change.

There is a great deal of research investigating obesity and the problems it causes. On the other hand, there is limited research on why providers do not provide more weight loss counseling. Furthermore, there is little research specific to NPs and the barriers to weight loss counseling. It may, therefore, be difficult to generalize this limited research to NP practice.

Strengths 

A majority of barriers to weight loss counseling, such as lack of time, were found in multiple studies (Table 2). Even though the study populations were small and largely homogenized in their practice setting, collectively, the findings were very similar. Six of the 7 studies identified lack of time as a barrier. Additionally, there were only a few studies that identified barriers not found in other articles, such as the barrier of focusing solely on the acute problem, and this barrier may be related to lack of time. Even with the weaknesses, a major strength between these varied studies is that the majority of barriers to weight loss counseling are similar among the cited studies.17, 23, 24, 25, 26, 27, 28

The studies have varied populations when considered collectively. Individually, the studies have homogenous populations, with the exception of Kushner's study, which used a randomized survey among members of the American Medical Association.24 When the individual studies are considered as a whole, generalizability of the identified barriers is increased. The findings are similar despite different study methods, different populations, and even different countries. This strengthens the overall validity of the identified barriers to weight loss counseling.

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Recommendations 

Based on the findings of these studies, some recommendations for practice can be made. It may be difficult to specify recommendations to NPs because of the lack of research among NPs. However, there was a consensus among all the studies using different provider populations on the perceived barriers to weight loss counseling. Further research is needed to look specifically at NPs and determine if these or other barriers are influencing weight loss counseling. General recommendations are possible when looking at a broader population based on the similarity of the identified barriers.

Time. The lack of time was the most often cited barrier in the studies. More time may need to be allotted for patient appointments in weight loss counseling. The USPSTF found intensive counseling to be effective in weight loss management.15 A study of NPs in 2006 found the average NP-patient encounter time to be 16 minutes with discussion how appointment time had decreased “from 35 min in 1993 to 20.4 min in 2001.”29 In comparison, a study of primary care MDs found an average of 10.1 minutes spent in face-to-face patient contact during visits.30 Realistically, coupled with the other barriers, including the belief that weight loss counseling may not be effective and the lack of reimbursement, providers may not be able to devote more time to weight loss counseling. Education is needed to show providers the benefits of counseling and how to better use what time they have more effectively for obesity management. This might be accomplished through provider's basic education in graduate school.

It may not be possible to do effective counseling in a 10- or 15-minute problem-focused office visit. To provide successful counseling, patient visits may need to be lengthened, carried out more frequently, and involve the use of other resources, such as dieticians. In light of the obesity problem in the United States, the time and resources devoted to prevention may pay dividends in the long term. Research is needed to investigate the effectiveness of brief counseling versus longer counseling sessions to determine the best intervention.

Provider education and confidence. Providers need training on nutrition and counseling techniques to better provide weight loss counseling. As training in nutrition and counseling techniques improve, providers' confidence levels in their ability to provide obesity counseling may increase. Research is needed to determine if weight loss counseling and nutrition education would improve counseling rates. Studies have shown that weight loss counseling is effective.15 One study reported a sustained 3.5-kg weight loss after 2 years as a result of counseling.31 Education during professional meetings on current research may increase provider confidence on the effectiveness of weight loss counseling and increase provider use.

Reimbursement. Currently, weight loss counseling is poorly reimbursed, if at all. As obesity and the associated co-morbidities increase, counseling provides a starting place to combat this problem. Overall, the focus on prevention may be more effective and less costly than obesity treatment and the associated co-morbidities but, again, more research needs to be done to quantify this. Nurse practitioners, with their focus on prevention, can influence policy and procedure changes to increase reimbursement for weight loss counseling with further research.

Poor guidelines. Obesity counseling guidelines need to be clarified, making it easier for providers to follow evidence-based practices. Two studies found guidelines to be a barrier to obesity counseling.25, 27 While additional research may be needed to strengthen current guidelines, providers should still practice based on the best research currently available. The USPSTF has provided current guidelines for weight loss counseling.15 Current USPSTF guidelines recommend obesity screening for all patients by calculating BMI and providing face-to-face counseling at least twice a month for the first 3 months of treatment.16

Other barriers. Further research is needed to better define additional barriers to weight loss counseling and to determine best practice. The research is particularly limited as it relates to NPs. It is likely that the barriers identified by NPs will be similar to the barriers identified by other providers, but further research is needed before additional recommendations can be made regarding NPs.

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Implications for NP Practice 

A more active approach should be taken by NPs to provide obesity counseling in clinical practice and work to improve reimbursement for this preventive service. There is a definite lack of research on obesity counseling barriers specific to NPs. Research is needed to identify if additional basic educational preparation in NP graduate programs is required. Additional education may be needed in periodic continuing education conferences both locally and nationally.

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Conclusion 

The problem of obesity has been increasing in recent years and is having a major impact on health care in the United States. While research has shown the benefit of weight loss counseling, it is not regularly done in primary care. The purpose of this integrative literature review was to evaluate barriers to weight loss counseling and to determine what actions are warranted to help improve practice specific to NPs. Several studies looked at barriers to obesity counseling. Barriers identified by the studies were outlined along with recommendations based on the findings.

The major finding of this review is the overall lack of research for NPs. The barriers to obesity counseling have been identified in different provider populations and are similar, but more research is needed with NPs. Keeping with the mandate of clinical prevention as stated by the AANP and ACNP, NPs need to take the time to provide obesity counseling and become actively involved in policy change and development.

Obesity is fast approaching smoking as the number one preventable cause of death in the United States.32 In addition, the increasing health care costs of obesity and its co-morbidities make it a major issue facing the United States today. Improving weight loss counseling may help reduce the incidence of obesity and provide a method to decrease the associated health problems. NPs have an opportunity to take a leading role in the obesity epidemic facing the United States today.

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References 

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 CE credit is available without charge online at www.npjournal.com or for $10 per credit hour by mail.In compliance with national ethical guidelines, the authors report no relationships with business or industry that would pose a conflict of interest.

PII: S1555-4155(08)00466-2

doi:10.1016/j.nurpra.2008.08.018

The Journal for Nurse Practitioners
Volume 5, Issue 3 , Pages 161-167, March 2009

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