a literature review and meta-analysis of survey data - Mednet

REVIEW

Physician weight loss advice and patient weight loss behaviorchange: a literature review and meta-analysis of survey dataSA Rose1,2, PS Poynter1, JW Anderson1, SM Noar3 and J Conigliaro4

Primary care providers (PCPs) can empower their patients to make health-promoting behavior changes. Many guidelinesrecommend that PCPs counsel overweight and obese patients about weight loss, yet few studies examine the impact ofprovider weight loss counseling on actual changes in patient behavior. We performed a systematic review and meta-analysis ofpublished studies of survey data examining provider weight loss counseling and its association with changes in patient weightloss behavior. We reviewed the published literature using keywords related to weight loss advice. We used meta-analytictechniques to compute and aggregate effect sizes for the meta-analysis. We also tested variables that had the potential tomoderate the responses. A total of 32 studies met criteria for the literature review. Of these, 12 were appropriate for themeta-analysis. Most studies demonstrated a positive effect of provider weight loss advice on patient weight loss behavior.In random effects meta-analysis, the overall mean weighted effect size for patient weight loss efforts was odds ratio (OR)¼ 3.85(95% confidence interval (CI) 2.71, 5.49; Po0.01), indicating a statistically significant impact of weight loss advice. There was nosignificant difference in the effectiveness of advice in studies using obese patients alone versus mixed samples (obese aloneOR¼ 3.44, 95% CI 2.37, 5.00; mixed sample OR¼ 3.98, 95% CI 2.53, 6.26, P¼ 0.63). PCP advice on weight loss appears to have asignificant impact on patient attempts to change behaviors related to their weight. Providers should address weight loss withtheir overweight and obese patients.

International Journal of Obesity (2013) 37, 118--128; doi:10.1038/ijo.2012.24; published online 27 March 2012

Keywords: physician; counseling; documentation; patient behavior; meta-analysis

INTRODUCTIONObesity is a major clinical and public health problem associated withan increased risk of morbidity and mortality and is related to manycomorbidities treated by primary care providers (PCPs).1,2 Intentionalweight loss can potentially mitigate this increased risk.3,4 Studies ontobacco and alcohol use counseling in the clinical settingdemonstrate that physicians can have a positive impact on changingpatient behaviors, even with brief counseling.5,6 Advocating similarmethods, multiple organizations recommend physician screeningand counseling for overweight and obesity, but most physicians donot appear to be advising their patients to lose weight.7 -- 12

Lack of physician counseling may be related to controversyregarding the effectiveness and realistic nature of weightcounseling. The United States Preventive Services Task Force(USPSTF) found good evidence to recommend that cliniciansscreen all patients for obesity through measurement of body massindex. However, they found fair to good evidence that only ‘high-intensity counseling and behavioral interventions’, defined asmore than one person-to-person session during at least the first 3months, were effective for treatment purposes, and that evidencefor less-intensive interventions that may be more feasible in theclinical setting was insufficient.8 The few studies that addresshealth care provider self-efficacy on the topic of weight find thatproviders face challenges with weight counseling, including a lackof tools, training, reimbursement, staffing and time, and relay alack of confidence in their own abilities and in the effectiveness ofweight loss strategies in general.10,13 -- 17

The purpose of this study was to examine whether PCPcounseling enhances patient engagement in weight reductionefforts. We aimed to systematically review the survey literatureregarding the effectiveness of PCP-provided advice related topatient weight loss behaviors, followed by a meta-analysisexamining the hypothesis that PCP counseling would enhancepatient participation in weight loss efforts.

MATERIALS AND METHODSLiterature review search strategyWe performed an extensive search related to the effect of provider weightloss advice on patient behavior. We conducted a review of publishedliterature in the English language using numerous keywords in combina-tion relating weight loss advice, including physician, counseling, over-weight, obese, weight loss, advice, diagnosis, documentation, recording,recognition, screening and cardiovascular risk. We performed searches inPubMed, Web of Science, PsycINFO, Cochrane Library, ERIC, Dissertationand Theses and WorldCat, and used PubMed MeSH headings andanalogous search strategies in other databases. No limitations were madeupfront; however, one relevant non-English language article was excludedfrom the coding. Searches included articles published through Novemberof 2011. An initial search using PubMed alone found five articles with theoutcome appropriate for inclusion in the meta-analysis,18 -- 22 with one laterremoved in favor of an article using the same data set with a larger, moregeneralizable population.21 The list of references for each of these articleswas searched for additional potential articles.

Received 18 August 2011; revised 17 January 2012; accepted 21 January 2012; published online 27 March 2012

1University of Kentucky College of Medicine, Department of General Internal Medicine and Geriatrics, Lexington, KY, USA; 2University of Kentucky College of Public Health,Department of Epidemiology, Lexington, KY, USA; 3University of North Carolina at Chapel Hill School of Journalism and Mass Communication, Chapel Hill, NC, USA and 4New YorkUniversity School of Medicine, Department of Medicine, New York, NY, USA. Correspondence: Dr SA Rose, University of Kentucky College of Medicine, Department of GeneralInternal Medicine and Geriatrics, 740 South Limestone, K507, Lexington, KY 40536-0284, USA.E-mail: sro226@email.uky.edu

www.nature.com/ijo

Inclusion criteria included all of the following: patient impression of theefficacy of PCP weight loss advice or counseling on overweight status asnoted through survey or observational study data; evaluation of thediscussion of overweight status between a patient and his/her providerduring an office visit; inclusion of patients of all weights, provision or self-reported or chart-documented information about physician advice andweight history; and written in English. Because many studies did notspecify, studies involving any PCP, such as a physician, nurse practitioner orphysician assistant, were included in this review, and we use the termsprimary care provider or provider to mean any of these practitioners.

Article codingWe used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria for reporting our meta-analysis.23 Articles werecoded on multiple dimensions by two coders including demographicssuch as age; clinical characteristics such as body mass index; surveycharacteristics such as method of survey participation (telephone,in-person or written), deliverer of weight loss advice (attending physician,resident physician or other provider), type of practice (internal medicine,family practice, pediatrics, other) and survey type and year, andmethodological characteristics including type of counseling receivedregarding weight loss and type of counseling received regarding physicalactivity or dietary change or decreasing comorbidities. Because some ofthe articles presented outcomes in adjusted form, we coded foradjustment. Satisfactory intercoder reliability was established with anaverage percent agreement across all categories of 86% (k¼ 0.75), withcoding differences resolved through discussion. To assess study quality, weused a standardized abstraction form by Zaza et al.,24 the purpose of whichis to assess the quality of the study across six categories, includingintervention and study descriptions, sampling, measurement, analysis,interpretation of results and other execution issues. Two coders calculatedthe quality of each article on each category, and differences were resolvedthrough discussion.

Effect size extraction and calculationThe odds ratio (OR), or the odds of an event occurring in an exposedpopulation divided by the odds of an event occurring in an unexposedpopulation, was used as the effect size indicator. We calculated effect sizesfrom data from each article using appropriate formulas. The primaryexposure was provider weight loss advice, and the primary outcome waspatient weight loss attempt. We used meta-analytic techniques tocompute and aggregate effect sizes for the 12 studies that met inclusioncriteria. We also carried out sensitivity analysis on variables believed tohave the most potential to moderate the responses.

Meta-analytic approachWe used Microsoft Excel to calculate totals, means and medians for ourdemographic and clinical characteristics. We used the ComprehensiveMeta-Analysis software program, version 2.0 (ComprehensiveMeta-Analysis, Englewood, NJ, USA), to calculate effect sizes and weightthem by sample size. We combined the effect sizes using standard randomeffects meta-analytic procedures and presented them with their 95%confidence intervals (CIs). We used the Q statistic and the I2 statistic to lookfor significant heterogeneity among the effect sizes. In testing categoricalvariables that had the potential to moderate the responses, we calculatedthem along with their 95% CIs, and compared them with one anotherusing the Qb and I2 statistics.25 Attempts were made to contact authorswhen additional raw data were needed.

RESULTSWe found 6041 nonduplicate articles for possible inclusion(Figure 1). A number of these articles had low relevancy to thestudy, whereas many were background information about theevolution of the obesity issue and guidelines or editorialsregarding recommendations for provider counseling and

treatment. There were also hundreds of articles dealing withinterventions that went beyond provider advice. A total of 32studies were appropriate for the literature review.18 -- 22,26 -- 52

Of these, 22 had the outcome appropriate for the meta-analysis.Of these 22, 10 were excluded for two reasons. One was use of asimilar data set and time point (Behavioral Risk Factor SurveillanceSurvey (BRFSS); n¼ 11 of 22, or National Health and NutritionExamination Survey (NHANES; n¼ 4 of 22)). Of those from thesame year, we used studies with a larger n and a moregeneralizable population. The other reason was inappropriatereporting of outcomes (n¼ 2) for calculation in the meta-analysis.In the literature review we included all studies that met inclusioncriteria in order to demonstrate the wealth of papers published onthis topic, as well as the consistency of findings through differenttime points and populations. In all, 12 studies were appropriate formeta-analysis. Our literature review assesses the effectiveness ofPCP-provided advice related to six different patient weight lossbehaviors, and our meta-analysis examines the correlationbetween PCP counseling and weight loss efforts.

Literature reviewThe literature review identified 32 reports with analyzabledata18 -- 22,26 -- 52 related to PCP advice regarding patient overweightand changes in behavior compared with patients not receivingadvice. These reports summarized advice from providersregarding weight loss, including the following exposures:(1) advice to lose weight by a provider; (2) specific PCP advicerelated to weight loss; (3) information or communication from thePCP regarding overweight; (4) and provider use of motivationalinterviewing to promote weight loss (Table 1). The majoroutcome focused on increased patient action toward weight loss,and specifically included: (1) patient engagement in weightloss efforts; (2) patient perception of weight loss advice, includingperceived success of provider weight loss advice, patient desirefor weight loss, and patient confidence in ability to lose weight;(3) patient stages of change, either for readiness to lose weight orfor readiness to change weight-related behavior; (4) patientweight maintenance attempt; (5) patient attempt at a specificbehavior change related to weight loss; and (6) actual patientweight loss (Table 1). Several studies contained more than oneoutcome.

(1) Patient engagement in weight loss efforts (Table 1,category 1)In all, 22 studies looked for an association between weight lossadvice and patient engagement in weight loss efforts (Table 1). Ofthe 22 studies, 11 used data from the BRFSS, 4 used NHANES data,1 used National Health Interview Survey (NHIS) data and 6 usedlocal study data (Table 1). Only one did not find a positiveassociation.29

The BRFSS is a standardized, nationwide telephone survey ofadults X18 years of age to which states can attach separatemodules asking questions focusing on specific comorbidities. Thesestudies focused on questions regarding weight management. A fewstudies evaluated subsets of the general US population, such aspatients with comorbidities, veterans, specific states or certain racesand ethnicities. All demonstrated a positive association between PCPweight loss advice and patient weight loss efforts (Table 1). NHANESis an annual national survey that assesses the health and nutritionalstatus of children and adults in the United States through in-personinterviews and physical examinations.53 All four studies20,26,45,47

using these data found positive associations between advice andweight loss efforts (Table 1).

(2) Patient perceptions of weight loss advice (Table 1, category 2)Eight studies evaluated the association between physician adviceand positive thoughts about weight loss by patients (Table 1). Sixstudies26,28,26,34,35,45,51 found some positive association between

Physician weight loss advice and patient changeSA Rose et al

International Journal of Obesity (2013) 118 -- 128& 2013 Macmillan Publishers Limited

PCP discussion of weight and patient confidence in the ability ordesire to lose weight (Table 1).

(3) Patient stage of change (Table 1, category 3)Four studies evaluated physician advice and patient stage ofchange, based on Prochaska’s transtheoretical model of the fivestages of change, which includes precontemplation, contempla-tion, preparation, action and maintenance (Table 1). This modelcan be used to determine a patient’s receptiveness to specificstrategies or actions. Despite differences in patient population anddefinition of positive stage of change, all but one52 found apositive association between physician advice and increased stageof readiness for weight loss (Table 1).

(4) Patient weight maintenance attempt (Table 1, category 4)All three studies assessing the correlation between PCP counsel-ing on weight loss or about overweight and weight lossmaintenance found a positive correlation between the two.20,27,47

Patient attempt at a specific behavior change related to weightloss (Table 1, category 5)

(5) Patient attempt at a specific behavior change related to weightloss (Table 1, category 5). In all, 11 studies examined the associationbetween provider weight loss advice and attempts by patients at

specific behavior changes related to weight. Of these 11, 8studies29,34,38,40,41,48,50,51 found a positive association betweenphysician weight loss advice and dietary change. All studies, exceptthose of Himmel et al.38 and Rodondi et al.,39 examined theassociation between weight loss advice and physical activity, butonly three found a positive association.28,48,51 Rodondi et al.39 founda positive association between physician weight loss advice andseeing a dietitian and setting a target weight, but not betweenadvice and reading self-help material to lose weight (Table 1).

(6) Actual weight loss by a patient (Table 1, category 6)A total of seven studies examined actual patient weight loss andits association to provider advice, and all found some positiveassociations between the two (Table 1). Singh et al.26 usedNHANES data and found a positive association between physiciandiagnosis of being overweight and intentional weight loss of X5%(prevalence ratio 1.87; 95% CI 1.61, 2.17). Singh et al.47 used thesame data set but looked specifically at patients with cardiovas-cular disease and central obesity, and found a positive associationbetween patient report of PCP recognition of overweight andintentional weight loss of X5% (OR 2.78, 95% CI 1.37, 5.63).

Himmel et al.38 surveyed overweight patients from a solophysician family practice in Northern Germany. Of those

Records after duplicates removed(n = 6041)

Records screened(n = 464)

Records excluded (n = 372)

Full-text articles assessedfor eligibility

(n = 87)

Inappropriate study type(n = 24)No link given betweenphysician recognition andpatient outcome (n=13)Advice provided forspecific comorbidity (n=5)No information oncomparison group (n=3)Abstract only (n=3)Foreign language (n=1)Thesis (n=4)Link between advice andoutcome inappropriatefor study (n=1)Inappropriately presentedoutcomes (n=1)Commentary (n=2)

Abstract published as complete study (n=1)Study re-reviewed and found appropriate for

literature review (n=1)

Studies included inquantitative synthesis

(meta-analysis)(n = 12 )

Studies included in qualitative synthesis (n = 32)

••••

Figure 1. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram of article search strategy.23

International Journal of Obesity (2013) 118 -- 128 & 2013 Macmillan Publishers Limited

Studiesincluded

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who ranked their communication with their physician as ‘good’,28% had lost at least 3 kg as compared with 20% who did not rankcommunication as good. Of those ranking communication as‘average’, 50% reported weight loss as compared with 55% whodid not rank it as average, and 12% ranking communication as‘poor’ reported losing weight when compared with 25% whodid not rank it as poor. Rodondi et al.39 conducted in-personinterviews and questionnaires with patients from Swiss university-affiliated primary care clinics. At the end of 1 year, questionnairecompleters (n¼ 407, 78%) who had received any form ofcounseling reported an average weight loss of 1 kg as comparedwith a gain of 0.3 kg (P¼ 0.002) in those who had not receivedcounseling. After adjustment, counseling with each additionalweight loss strategy was associated with a mean weight loss of0.2 kg (95% CI 0.03, 0.4, P¼ 0.02). Levy and Williamson43 surveyed56 obese adult patients from a midwestern university familypractice clinic, and found that those who lost weight (n¼ 21),defined as a loss of at least 2.3 kg over a 5-year period, reportedmore physician attention to their obesity.

Alexander et al.51conducted audio recordings of 40 physiciansand 461 of their overweight or obese patients looking for examplesof use of the 5A’s (Ask, Advise, Assess, Assist and Arrange) in weightloss counseling, and then conducted a post-visit survey andanthropometric measurement. They found a positive associationbetween 3-month weight loss and physician arrangement forfollow-up with physician or nutritionist regarding weight loss(arranged: mean (pre)¼ 101.4 kg (s.e. 3.49) versus mean(post)¼ 99.9 kg (s.e. 3.51); did not arrange: mean (pre)¼ 91.1 kg(s.e. 0.76) versus mean (post)¼ 91.2 kg (s.e. 0.76), P¼ 0.05). Pollaket al.46 used the same population as Alexander et al.51 to assess thedifference in patient weight loss between patients receivingphysician weight loss counseling versus not, and physician use ofmotivational interviewing techniques. They found a statisticallysignificant weight loss in those patients whose physicians exhibitedmotivational interviewing spirit (�1.6 kg (�2.9, �0.3), P¼ 0.02) andexhibited reflection or understanding of the patient’s statements(�0.9 (�1.8. �0.1), P¼ 0.03), but no statistically significant weightchange for other physician behaviors.

Meta-analysisStudy characteristics. The 12 studies included a total of 207 226individuals, and were published between 1999 and 2011 (Tables 1and 2). All studies were conducted in the United States. Excludingtwo articles that did not give demographic information ongender29,31 and one that did not give demographic informationon race,31 60% of patients were female and 37% were white. Twostudies evaluated a pediatric population.20,29 There were 39 310(19%) patients who reported receiving advice to lose weightor being told that they were overweight. Two studies18,31 lookedonly at an obese population, whereas the rest includedoverweight patients; two studies22,41 included normal-weightpatients in their sample. Eight studies used national and fourused local survey data. One study did not provide the OR andinstead gave a prevalence ratio.26 Satisfactory quality wasestablished with an average percent agreement of 89% acrossall categories (k¼ 0.77).

Efficacy of intervention: weight loss attempt. All studies exceptone29 demonstrated a positive effect of PCP advice on patientengagement in weight loss efforts (Figure 2). The overall randomeffects mean weighted effect size for weight loss efforts includingall studies was OR¼ 3.85 (95% CI 2.71, 5.49; Z¼ 7.47, Po0.01),indicating a statistically significant impact of weight loss advice onefforts at weight loss. Removal of studies with different popula-tions such as children20,29 and removal of the study with theoutlying OR size for the outcome22 did not change the resultssignificantly.

(Continued

(Project

CHAT---CommunicatingHealth---

AnalyzingTalk)

andOBad

6Difference

inactual

ptWLove

r3months

betwee

receivingPCPWLco

unselin

ofMIco

unselin

niques

(6)WLco

unselin

g:+0.1kg

(�0.7,

P¼0.84

unselin

niques

MIspirit:�1.6kg

(�2.9,�0.3;

P¼0.02

ection:�0.9kg

(�1.8,�0.1;

P¼0.03

questions:+0.1kg

(�0.8,

P¼0.86

pathy:�1.0kg

(�2.8,

P¼0.26

nsisten

aviors:�1.1kg

(�2.3,

P¼0.07

Abbreviations:5A

’s,Assess,Advise,A

gree,Assistan

dArran

ge;BMI,bodymassindex;B

avioralR

iskFactorSu

rveillance

System

interval;C

VD-TI,CardiovascularDisease

Targeted

Initiative

;MI,motivationalinterviewing;n

,number;N

,NationalHealthan

dNutritionExam

inationSu

;NHIS,N

ationalHealthInterview

Survey

bese;OR,o

ddsratio;O

eight;PA

,physical

activity;PCP,primarycare

provider;PrR,p

revalence

ratio;p

t,patient,Ref,referen

ce;sxs,sym

ptoms;VA

,Veteran

sAdministration;W

L,weightloss;w

t(s),w

eight(s).Exp

osures:(1)P

CPweightloss

advice,either

healthorto

improve

aspecificco

morbidity;

(2)specificPCPad

relatedto

weightloss;(3)

inform

ationorco

mmunicationfrom

thePCPregardingove

rweight;(4)PCPuse

ofMIto

promote

weight

loss.O

utcomes:(1)

Patien

weightloss

efforts;(2)patientperceptionofweightloss

advice,includingperceived

successofprovider

weightloss

advice,p

atientdesireforweightloss

andpatient

confid

tolose

weight;(3)patientstag

esofch

either

forread

inessto

weightorforread

inessto

geweight-relatedbeh

avior;(4)patientweightmaintenan

ceattempt;(5)patient

attemptat

aspecificbeh

aviorch

angerelatedto

weightloss;(6)actual

patientweightloss.

Characteristicsofstudiesincluded

inthemeta-an

alysisevaluatingassociationbetwee

nprovider

advice

andpatientweightloss

attempt

ultsfrom

states,

eight,ove

rweightan

dobesead

Telephone

S,national

0)Male¼10

.13(8.53,

12.03)

Po0.01

Female¼6.24

(5.5,7.09

)Z¼28

Po0.01

Dorsey

Songer

Nationwidesample

(n¼56

3withprediabetes

42withdiabetes)

rweightan

dobesead

ultswith

prediabetes

anddiabetes

In-person

NHIS,national

6)aPred

iabetes

M¼notcalc

iabetes

F¼notcalc

Diabetes

M¼9.1(5.4,15

Z¼8.26

Po0.01

Diabetes

F¼4.1(2.5,6.7)

Z¼5.70

Po0.01

Nationwidesample

Obesead

Telephone

S,national

5)4.17

(3.74,

)Z¼25

Po0.01

Galuska

Nationwidesample

Obesead

Telephone

S,national

6)2.85

(2.63,

)Z¼25

Po0.01

ultsfrom

twoprimarycare

clinicsaffiliatedwithLo

uisianaState

University

rweightan

dobesead

In-person

Local(200

(2.70,

14.10)

Z¼4.32

Po0.01

dMiner

716teen

--19yearsfrom

50states

At-risk

foroverw

eightan

rweightad

olescen

ts(BMIX

percentile)

In-person

NHANES

,national

(1.74,

)Z¼5.56

Po0.01

oftotalsample)ad

Connecticu

rweightad

Telephone

S,national

(state

Connecticu

tonly)(199

4)7.51

(3.71,

15.21)

Z¼5.60

Po0.01

Nationwidesample

rweightan

dobesead

In-person

NHANES

,national

(2.55,

)Z¼18

Po0.01

Saelen

adolescen

--18years

RhodeIslandan

dCalifo

rweightad

olescen

ts(BMIX85

thpercentile)

In-person

Local(200

2)1.58

(0.68,

)Z¼1.05

P¼0.29

Singhan

Nationwidesample

rweightad

In-person

NHANES

,national

PR¼1.49

(1.42,

)Z¼15

Po0.01

ultpatients

aninternal

icineclinic

atColumbia

University,New

eight,ove

rweightan

dobesead

In-person

S-based

,local(200

.03(6.63,

49.04)

Z¼5.67

Po0.01

ulthospital

employees

ahealthcare

system

incentral

Massach

usetts

rweightan

dobesead

In-person

Local(200

5)White1.18

(1.03,

)Z¼2.40

P¼0.02

African

American

(1.53,

)Z¼3.40

P¼0.00

Abbreviations:BMI,bodymassindex;B

avioralR

iskFactorSu

rveillance

System

;CI,co

interval;F,fem

NHANES

,National

Healthan

dNutritionExam

inationSu

;NHIS,N

ational

HealthInterview

Survey

;OR,oddsratio.aNotcalculatedbecau

seofsm

allsample

sizes.

Heterogeneity and intervention moderators. We found significantheterogeneity of the effect sizes among the studies (Q¼ 1124.09,I2¼ 98.76, Po0.01), and therefore looked at between-studymoderators that could impact the association of advice andengagement in weight loss efforts. Using random effects analysis,we found no statistically significant difference in the effectivenessof advice in studies using obese patients alone versus mixedsamples (OR¼ 3.44, 95% CI 2.37, 5.00 versus mixed sampleOR¼ 3.98, 95% CI 2.53, 6.26, P¼ 0.63), studies using nationalversus local survey data (OR¼ 4.19, 95% CI 2.75, 6.38 versus 3.33,95% CI 1.36, 8.15, P¼ 0.65) or from data published before the 1998NHLBI (National Heart, Lung, and Blood Institute) guidelines on theidentification, evaluation and treatment of overweight and obesitycompared with after publication (OR¼ 4.33, 95% CI 1.69, 11.09versus 3.81, 95% CI 2.48, 5.85, P¼ 0.81). We did find a significantdifference in patient report of weight loss attempt if advised bytheir PCP in adults versus children (OR¼ 4.24, 95% CI 2.90, 6.22versus 2.24, 1.69, 2.98, P¼ 0.01), and in patients who weresurveyed by telephone compared with in-person survey(OR¼ 5.50, 95% CI 3.46, 8.72 versus 3.00, 95% CI 2.15, 4.17,P¼ 0.04).

DISCUSSIONIn this literature review and meta-analysis we assessed studiesaddressing communication between PCPs and patients regardingweight. Our literature review consistently demonstrated thatphysician advice can have a positive effect on patient actionregarding weight loss. Our meta-analysis indicated that providerweight loss advice has a statistically significant impact on patientattempt to lose weight, suggesting that brief counseling by theprovider may play a role in patient weight management.

In our meta-analysis, comparison of data before and after the1998 NHLBI guidelines did not find a significantly positive impactof guideline publication on the association between provideradvice and patient weight loss efforts. Caution should be takenwith these results as there were only two studies that used databefore the 1998 guidelines, both of them larger studies usingnational or state-based data as opposed to smaller local studies.Caution should also be taken with our finding of a significantdifference in patient report of weight loss attempt if advised bytheir PCP in adults versus children (OR¼ 4.24, 95% CI 2.90, 6.22versus 2.24, 1.69, 2.98, P¼ 0.01), because of the small number andtotal n of studies including children. Further study is needed tobetter evaluate and identify a true significance in the differencewe found in patient report of weight loss attempt between

patients who were surveyed by telephone compared with in-person (OR¼ 5.50, 95% CI 3.46, 8.72 versus 3.00, 95% CI 2.15, 4.17,P¼ 0.04). In-person surveys included both large national studies(NHANES and NHIS) that are conducted in person and smallerlocal surveys, whereas telephone surveys consisted solely of largenational surveys, and these two may not be easily compared.

We found no significant difference in the correlation betweenprovider advice and weight loss attempt in obese-only versusmixed-weight samples in our meta-analysis. Again, there were asmall number of obese-only studies, requiring caution withinterpretation. Rodondi et al.39 and Sciammana et al.40 bothreport that obese patients, especially those with an obesity-relatedcomorbidity, are more likely to receive weight loss advice fromtheir physicians compared with overweight patients. However,Sciammana et al.40 found that patients in lower overweight bodymass index categories were more likely to act on such advicecompared with obese patients with a body mass indexof X30 kg m -- 2. Bish et al.41 had similar findings to those ofSciammana et al.40 and advise caution with these findings, aspatients may have lost weight since receiving physician advice, ormay have sought assistance with their weight from a medicalprofessional because of feelings about their weight, regardless oftheir actual weight.39

Only studies assessing the correlation between provider weightloss advice and specific behavior change attempt related tophysical activity demonstrated a negative correlation. This may berelated to providers’ overall discomfort and limited knowledge ofthese topics.54,55

Importantly, we found that all studies that looked at theassociation between provider weight loss advice and actualpatient weight loss found a positive association between the two.This positive association was found in studies of different sizes andpopulations. Furthermore, it was demonstrated in populationswho received both advanced counseling and simple PCPrecognition or diagnosis of overweight and obesity.

LimitationsThis study contains several limitations. One is the small number ofstudies included in the meta-analysis. Because of repeat use ofsimilar data sources or inappropriate outcome data, we wereunable to use many potential studies. However, reliability isdemonstrated by the relative consistency of the effect sizes andpositive direction in nearly all studies. The meta-analysis containsstudies of differing sizes and potentially of differing quality,possibly affecting outcomes. This is demonstrated further in themoderator analysis of national versus local studies, whichessentially separates out studies with the smallest and largestsample sizes, but from which we found no significant difference.Meta-analysis calculations attempt to take into account study sizewhen calculating effect size but cannot discern quality. However,all were published in peer-reviewed publications, many used well-validated surveys and techniques for obtaining subjects and ourquality calculation revealed adequate agreement.

Inability to obtain raw data led to use of studies with bothadjusted and unadjusted data. However, adjusted ORs will tend tobe smaller, underestimating the effect of the exposure rather thanoverestimating it. The use of the prevalence ratio instead of theOR to display effect size in one study26 tends to underestimatethe effect size compared with the OR, giving little concern thatthis study would cause overestimation of the effect of theexposure on the outcome. As groups of studies were divided intovarious categories, the number of studies in each group (k)became small, which can lead to reduction in statistical power todetect significant differences, particularly in the case of randomeffects analyses.25

This study evaluates the effect of PCP advice on behaviorchange, potentially considered an intermediate outcome, whereas

Study name Odds ratio and 95% CI

Bish et al. (Male)Bish et al. (Female)Dorsey et al. (Diabetic Male)Dorsey et al. (Diabetic Female)Felix et al.Galuska et al.Huang et al.Kant et al.Nawaz et al.Post et al.Saelens et al.Singh et al.Thande et al.Zapka et al (White)Zapka et al (African-American)

0.01 0.1 1 10 100

No provider advice Provider advice

Figure 2. Odds ratios for the effect of provider advice on patientweight loss attempt for each study and overall in the meta-analysis.

only five of seven studies evaluating the outcome of actual weightloss used independent data for meta-analysis. Because of thissmall number, the heterogeneity of these studies and thedifference in their outcomes, meta-analysis of these studies wouldnot provide meaningful data. However, examining patientbehavior change in the context of provider advice is an outcomeworthy of evaluation and the overwhelmingly positive outcomesshould encourage more providers to talk to their patients aboutweight.

ConclusionsThe rapidly growing prevalence of obesity and its associated riskshave increased the importance of the role that the PCP can play.This study assesses the importance of weight loss advice by thePCP. We found that provider weight loss advice positively affectspatient weight loss behavior in all outcomes addressed. Morestudies and interventions are needed to clarify the role ofproviders in this interaction and to overcome barriers to providerself-efficacy regarding counseling during the clinic visit. Policy-makers should recognize the provider’s need for additional timeand training in advising their patients as well as improvements inreimbursement and provision of tools such as dietitians. Perhapsmost importantly, PCPs need to recognize their influence when itcomes to advising their patients about their weight.

CONFLICT OF INTERESTDr Anderson currently has research support from Health Management Resources(HMR), and is a consultant to HMR.

ACKNOWLEDGEMENTSWe thank James Meigs and Elisabeth Watkins for review and editing of thismanuscript. We thank Heather Bush and Daisuke Sugimoto for assistance withbiostatistical analysis and editing.

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