Nutrition and physical activity guidance practices in general practice: A critical review

Patient Education and Counseling 90 (2013) 155–169

Review

Nutrition and physical activity guidance practices in general practice:A critical review

Sonja M.E. van Dillen a,*, Jaap J. van Binsbergen b, Maria A. Koelen c, Gerrit J. Hiddink a

a Strategic Communication, Wageningen University, Wageningen, The Netherlandsb Department of General Practice, Radboud University Medical Centre, Nijmegen, The Netherlandsc Health and Society, Wageningen University, Wageningen, The Netherlands

A R T I C L E I N F O

Article history:

Received 15 May 2012

Received in revised form 17 September 2012

Accepted 6 October 2012

Keywords:

General practice

Obesity

Diet

Exercise

Health education

Prevention and control

Review

A B S T R A C T

Objective: The aim of this critical review is to provide insight into the main outcomes of research on

communication about nutrition and/or physical activity between GPs and patients for prevention or

treatment of overweight and obesity.

Methods: Relevant studies were identified by a computerized search of multiple electronic databases

(MEDLINE, PsycINFO) for all available papers between 1 January 1995 and 1 January 2012. In addition,

two independent reviewers judged all studies on ten quality criteria.

Results: In total, 41 studies were retrieved. More studies were found about the guidance of obese

patients than of overweight patients. The most common weight guidance practice was discussion of

weight. The range of communication strategies for nutrition showed to be more diverse than for physical

activity. Twelve studies were considered as high-quality studies, 18 were having medium quality, and 11

were seen as low quality.

Conclusion: We reflected on the fact that the content of advice about nutrition and physical activity was

quite general. GPs’ provision of combined lifestyle advice to overweight and obese patients seems to be

rather low.

Practice implications: Observational research is needed to unravel the quality of the advice given by GPs

to overweight and obese patients.

� 2012 Elsevier Ireland Ltd. All rights reserved.

Contents lists available at SciVerse ScienceDirect

Patient Education and Counseling

jo ur n al h o mep ag e: w ww .e lsev ier . co m / loc ate /p ated u co u

1. Introduction

Evidence is emerging that the prevalence of overweight andobesity is increasing worldwide at an alarming rate [1]. In theNetherlands, almost half of the population is overweight [2]. Poordiet and physical inactivity increase the risk of several healthproblems, including obesity.

These findings have led to the development of multiplerecommendations about nutrition [3–5]. According to the DutchDietary Guidelines for example, consumers are recommended toeat a balanced diet, be sufficiently physically active every day, eatplenty of vegetables, fruits and whole grains products, eat (fatty)fish regularly, limit saturated fatty acids and trans fatty acids, limitintake of foods and drinks with added sugars, reduce sodiumintake, and moderate alcohol intake [4].

Also several recommended guidelines about physical activityhave been developed, that range from at least 30 min of

* Corresponding author at: Strategic Communication, Wageningen University,

P.O. Box 8130, 6700 EW Wageningen, The Netherlands. Tel.: +31 317 482551;

fax: +31 317 486094.

E-mail address: [email protected] (Sonja M.E. van Dillen).

0738-3991/$ – see front matter � 2012 Elsevier Ireland Ltd. All rights reserved.

http://dx.doi.org/10.1016/j.pec.2012.10.022

moderate-intensity physical activity on five or more days ofthe week to 20 min of vigorous-intensity on three or more days ofthe week [6–8].

Recommended guidelines can be delivered by general practi-tioners (GPs) to their patients. GPs are ideally placed to promotehealthy nutrition and physical activity. Patients perceived GPs asthe most reliable source of nutrition information [9,10] or physicalactivity information [11]. The percentage of overweight and obeseindividuals seen in general practice even exceeds the percentagefound in the general population [12]. Apart from the generalguidelines about nutrition and physical activity, specific guidelinesfor the identification and management of obesity have beendeveloped for health professionals [13–15]. These guidelines mayoffer GPs recommendations to support their daily guidancepractices.

However, it is not known to what extent GPs actually guidetheir patients on nutrition and/or physical activity to prevent ortreat overweight and obesity. Understanding of their specificguidance practices used in daily practice is needed in order todevelop appropriate interventions for overweight in the generalpractice, and to highlight these in medical education.

Therefore, the aim of this critical review is to provide insightinto the main outcomes of research on communication about


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S.M.E. van Dillen et al. / Patient Education and Counseling 90 (2013) 155–169156

nutrition and/or physical activity between GPs and patients forprevention or treatment of overweight and obesity.

The following research questions will be answered:

� What is known about the main outcomes of studiesconducted regarding GPs’ (nutrition and/or physical activity)guidance practices in order to prevent or treat overweight orobesity?� What is known about the extent to which GPs integrate both

nutrition and physical activity guidance practices into preven-tion or treatment of overweight and obesity?� What are the specific nutrition and/or physical activity

communication strategies of GPs in their management ofoverweight and obesity?� What can be noticed about the study quality of these studies?

2. Methods

2.1. Search strategy

Relevant studies were identified by a computerized search ofmultiple electronic databases (MEDLINE, PsycINFO) with EBSCO-host as resource for all available papers between 1 January 1995and 1 January 2012. Moreover, we systematically screened thereference lists of (review)articles for other potentially relevantpapers.

The search strategy was based on the combination of fivedifferent categories, which had the following keywords in the titleor abstract:

1. GP (general practitioner or family doctor or primary carephysician or GP or PCP or general practice);

2. Patients with overweight or obesity (weight or overweight orobesity or adiposity or corpulence or obese or adipose);

3. Nutrition (nutrition or food or diet);4. Physical activity (physical activity or exercise or physical

fitness);5. Communication (communication or guidance or counseling or

education or promotion or advice or information or preventionor treatment or management or control or strategies or practicesor preventive behaviors).

2.2. Inclusion criteria

A study was included if:

� The study was written in English.� The study was an original paper.� The study addressed GPs’ nutrition guidance practices, physical

activity guidance practices, or combination with the aim toprevent or treat overweight or obesity.

A study was excluded if:

� The study was a review.� The study provided insight into knowledge, attitudes, task

perceptions or self-efficacy toward guidance practices, but noton guidance practices itself.� The study addressed guidance practices in children.� The study was about guidance practices of other health

professionals in general practice, such as nurse practitionersor practice nurses.� The study was conducted among GP trainees or residents.� The study concerned medical therapy.� The study was an intervention study.

The main reviewer (SvD) selected the studies on the basis of theabove-mentioned inclusion criteria. The second reviewer (GJH)independently checked whether these studies indeed met thesecriteria.

2.3. Assessment of methodological quality

The following data were extracted from the studies: country,study design, sample, response rate and main outcomes of thestudies with respect to weight guidance practices, nutritionguidance practices and physical activity guidance practices.

Next, two reviewers (SvD and GJH) independently assessed thestudy quality of the selected studies. The studies were judged onthe following quality criteria:

� Clear description of study aim (e.g. consistency in researchquestions, measurement instrument, results and conclusions);� Appropriate size of study population (e.g. report of the rationale

for sample size);� Sound selection of study population (e.g. random, stratified);� Representative sample (e.g. no over-representation of female

GPs, no over-representation of older GPs);� Good response rate (e.g. �80% for phone or face-to-face

interviews, �50% for mail questionnaires or classroom papers,�30 for Internet questionnaires) or low refusal rate/drop-out;� Efforts were undertaken to optimize response rate (e.g.

personalized letters, postage paid return envelope, reminders,incentives/gifts, simple and short measurement instrument,inclusion of group new respondents);� Measurement instrument was well-developed (e.g. based on

validated measures, prior research or reviewed literature);� Measurement instrument was tested before use (e.g. pilot-test,

pre-test for clarity, test–retest);� Appropriate measurement instrument (e.g. distinguishable

answer categories, Likert scales);� Suitable report of study limitations and shortcomings (e.g. to

overcome bias).

In total, ten plusses could be assigned. Studies with eightplusses or more were considered as high quality studies. Studieswith five, six or seven plusses were seen as medium quality, andstudies which obtained less than five plusses were considered aslow quality studies.

2.4. Theoretical framework

The 5A’s Model was chosen as theoretical framework to guideour research questions. The 5A’s Model [16] includes fivecomponents, namely:

1. Assess: ask about/assess behavioral health risks and factorsaffecting choice of behavior change goals;

2. Advise: give clear, specific, and personalized behavior changeadvice, include information about personal health harms andbenefits;

3. Agree: collaboratively select appropriate treatment goals andmethods based on patient’s interest in and willingness to changebehavior;

4. Assist: use behavior change techniques (self-help and/orcounseling), aid patient in achieving agreed-upon goals byacquiring skills, confidence, and social/environmental supportsfor behavior change, supplemented with medical treatmentswhen appropriate;

5. Arrange: schedule follow-up contacts to provide on-goingassistance and to adjust treatment plan as needed, includingreferral to more intensive or specialized treatment.

S.M.E. van Dillen et al. / Patient Education and Counseling 90 (2013) 155–169 157

3. Results

3.1. Review process

Fig. 1 outlines the method of article selection. A total of 182studies were identified in the electronic literature search. Reviewof these abstracts however revealed that 173 articles did not metour criteria. Reference lists of collected (review)articles werescreened for potentially relevant papers, resulting in another 32articles. Finally, in total 41 studies about this topic were retrievedfor this review and judged on its quality.

Main characteristics of the studies are summarized in Table 1,divided into country, study design, sample and response rate. Morethan half of the studies found was performed in the last five years.Table 1 also shows the main outcomes and study quality for studiesabout weight guidance practices (W), nutrition guidance practices(N) and physical activity guidance practices (PA).

3.2. Main characteristics

Of the 41 studies included in this review, 17 were conducted inthe USA. Fifteen studies were done in Europe, of which six in theUK. Seven studies were performed in Australia and two in Asiancountries.

All studies in this review were cross-sectional studies, exceptfor the longitudinal study of McAlpine and Wilson [17]. GP self-reports were the most common research method, especially mailquestionnaires were often used. Moreover, about 20% of theselected studies was based on patient recall and the samepercentage was found for chart audits. Six studies objectivelymeasured weight guidance by means of direct observation. Sixstudies used a combination of research methods, such as self-report and chart audit. One study evaluated patient–physicianagreement on discussing weight, nutrition and physical activity.This study showed that patients and GPs did not agree aboutwhether weight was reported for 39% of the visits [18].

Samples varied between 15 in a study with qualitativeinterviews and 13,859 in a Pan-European survey. Response ratesranged from 26% to 96%.

3.3. Weight guidance practices

Table 1 shows that there were more studies about the guidanceof obese patients than of overweight patients. A limited number of

Fig. 1. Flowchart for review of literature on nutrition and p

studies also considered severe obese patients. A couple of studiesaddressed three degrees of obesity. The most common weightguidance practice appeared to be discussion of weight. There werea couple of studies, in which body weight was actually measured,mostly by body mass index (BMI). Medication for weight loss wasseldom recommended. Furthermore, several lifestyle recommen-dations were part of their weight guidance practices, includingnutrition and physical activity promotion.

3.4. Nutrition and/or physical activity guidance practices

In total, 36 out of 41 studies included nutrition guidancepractices, and 35 out of 41 physical activity guidance practices.Remarkably, all studies performed in the last five years incorpo-rated physical activity guidance practices. Table 1 shows that thefrequency of nutrition guidance practices was often higher thanthat of physical activity guidance practices. The studies of Kreuteret al. [19] and Booth and Nowson [20] were the only ones, whichspecifically asked for the combination of receiving advice for dietplus exercise against diet only and exercise only.

3.5. Specific nutrition and/or physical activity communication

strategies

There were many different communication strategies reported.In one of the studies [21], GPs reported up to 25 weight lossstrategies. The following 14 specific strategies related to nutritionto reduce weight were communicated: reduce consumption of fastfood, reduce portion sizes, reduce soda consumption, eat a low-calorie diet, decrease the fat content of the diet, consume breakfast,refer to a dietician for individual counseling, use fat and/or caloriemodified foods, follow a specific calorie goal, eat a modified low-carbohydrate diet (i.e., <40 g carbohydrate), record food intake in adiary, eat a Mediterranean diet, eat a low-carbohydrate diet, anduse meal replacements. Seven specific physical activity-relatedstrategies to reduce weight were communicated: increase physicalactivity, suggest a specific type of physical activity, recommend aspecific intensity of physical activity, recommend locations towhich individuals can go to engage in physical activity, refer to acommercial program, decrease television viewing, and refer to anexercise specialist. Moreover, there were also four specificstrategies to reduce weight communicated: weight themselvesregularly, provide in-office educational materials, recommendInternet sources for weight loss, and use weight loss medication. In

hysical activity guidance practices in general practice.

Table 1Description of studies about GPs’ guidance practices to prevent or treat overweight or obesity, main outcomes and study quality.

Author, year,

country, reference

Study design, sample, response rate Main outcomes Study quality

Hølund et al., 1997,

Denmark [43]

Cross-sectional study, mail

questionnaire, 374 GPs, 37%

response.

W: 84% gave more advice on overweight than on underweight. Low

W: 50% recommended weight control when dealing with a slightly

overweight patient.

W: they recommended weight loss to a slightly overweight male

patient to a much greater extent than to an overweight female

patient.

N: 94% did not give dieting advice to a person without a diagnosis

of overweight.

N: 50% asked for a dietary record when dealing with a slightly

overweight patient.

N: they gave dietary counseling to a slightly overweight male

patient to a much greater extent than to an overweight female

patient.

N: they regarded slimming diets as the one of the most important

initiatives when dealing with a slightly overweight patient.

PA: they regarded physical activity as one of the most important

initiatives when dealing with a slightly overweight patient.

Kreuter et al., 1997,

USA [19]

Cross-sectional study, self-

administered questionnaire

completed in waiting room, 915

patients and 27 physicians of four

community-based

family medicine clinics, 96%

response.

N: 26% of patients with BMI < 27 reported a physical

recommendation to eat less fat in their diet.

Medium

N: 44% of patients with BMI � 27 reported a physical

recommendation to eat less fat in their diet.

PA: 22% of patients with BMI < 27 reported a physical

recommendation to increase physical activity.

PA: 44% of patients with BMI � 27 reported a physical

recommendation to increase physical activity.

N + PA: 11% of patients with BMI < 27 reported a physical

recommendation to eat less fat in their diet and to increase

physical activity.

N + PA: 27% of patients with BMI � 27 reported a physical

recommendation to eat less fat in their diet and to increase

physical activity.

Kristeller and Hoerr,

1997, USA [26]

Cross-sectional survey, mail

questionnaire, 1222 physicians, of

which 222 with specialty family

practice, 41% response.

W: they reported treating obesity in about 50% of obese patients

themselves.

High

W: they reported to make direct referrals for about 29% of obese

patients.

W: they reported that about 25% of patient would receive a

recommendation for treatment without a specific referral.

W: they most likely discussed health consequences of obesity.

W: they likely recommended that the patient seeks additional

help elsewhere.

W: they rather unlikely made formal referral to a weight-loss

program.

W: they least likely prescribed medication.

W: they likely provided counseling.

W: they likely provided written information.

W: they likely set follow-up visits.

W: they rather unlikely developed a specific plan.

N: they likely referred to a dietician.

Eley Morris et al.,

1999, UK [62]

Cross-sectional survey, postal


response.

W: 96% recorded motivation for losing weight among severe obese

patients.

High

W: 95% did measurement of height and weight in severe obese

patients.

W: 57% advised a weight reduction plan including a target weight

loss in severe obese patients.

W: 46% assessed support of family and friends among severe obese

patients.

W: 46% advised a rate of weight loss to morbid obese patients.

W: 3% prescribed drug therapy to morbid obese patients.

N: 98% recorded eating habits among severe obese patients.

N: 96% gave healthy eating advise to severe obese patients.

N: 74% discussed diets previously used with severe obese patients.

N: 53% issued diet sheet prepared by a dietitian to morbid obese

patients.

N: 6% advised a very low calorie diet (e.g. 800 kcal/day) to morbid

obese patients.

PA: 98% recorded current level of physical activity among severe

obese patients.

PA: 92% gave advice on exercise to severe obese patients.

PA: 53% prescribed an exercise plan to morbid obese patients.

Evans, 1999, UK [35] Cross-sectional study, self-

administered questionnaire, 370

obese patients who successfully lost

45 kg.

W: 80% of obese patients had previously been advised by their

doctor to lose weight.

Low

W: 43% received vague advice (e.g. lose weight, eat less).

W: 22% received positive advice.

W: 4% received advice to use weight loss drug.


Table 1 (Continued )

Author, year,

country, reference


N: 19% received diet sheet.

N: 9% received advice for dietitian referral.

N: 7% received general dietary advice (e.g. eat less fat).

N: 5% received poor dietary advice (e.g. eat nothing, drink water).

PA: 4% received advice to join slimming club.

Lawlor et al., 1999,

UK [63]



response.

PA: 77% indicated that they would give advice regarding physical

activity to overweight patients.

Medium

Campbell et al., 2000,

Australia [48]



response.

W: 85% usually reviewed their patients’ progress for more than 6

months.

High

W: 83% usually assessed patients’ weight history.

W: 78% usually assessed patients’ expectations of weight loss.

W: 68% usually assessed patients’ definitions of successful

outcomes.

W: 65% usually referred patients to other health care

professionals.

W: 78% usually assessed patients’ readiness for change.

W: 53% usually reviewed their patients’ progress for more than 2

years.

W: 48% usually assessed the home environment for support.

W: 14% usually saw patients together with a spouse or other.

N: 88% usually assessed patients’ dietary habits.

N: 98% usually provided specific advice to reduce total fat intake.

N: 96% usually provided specific advice to increase fruit and

vegetable intake.

N: 93% provided specific advice to reduce alcohol.

N: 83% provided specific advice to increase bread and cereal

consumption.

N: 78% provided specific advice to eat fewer kilocalories.

N: 54% provided specific advice to reduce dairy foods.

N: 50% provided specific advice to reduce red meat.

N: 27% provided practical advice regarding shopping and cooking.

N: 27% provided advice to keep an eating awareness diary.

PA: 94% usually assessed patients’ physical activity habits.

PA: 99% usually provided general advice to do more exercise or be

more active.

PA: 98% usually provided advice to incorporate low-intensity, long

duration activity such as walking into present lifestyle.

PA: 41% usually provided advice to join a community slimming

group.

PA: 13% usually provided advice to join a commercial slimming

group.

Wadden et al., 2000,

USA [30]

Cross-sectional survey,

questionnaire, 259 obese women.

W: 33% of obese patients reported that their doctor discussed

weight control with them at least at every other visit.

Medium

W: 17% of the doctors were reported by obese women to have

prescribed medication.

W: 15% of the doctors were reported to have prescribed readings.

N: 23% of the doctors were reported to have prescribed a diet plan.

N: 11% of the doctors were reported to have prescribed controlled

energy diet.

N: 7% of the doctors were reported to have prescribed eating

habits.

N: 7% of the doctors were reported to have made referrals to

dieticians.

PA: 19% of the doctors were reported to have prescribed a

commercial weight loss program (Weight Watchers).

PA: 13% of the doctors were reported to have prescribed an

exercise plan.

PA: 6% of the doctors were reported to have made referrals to

exercise instructors.

PA: 4% of the doctors were reported to have made referrals to other

commercial programs.

Potter et al., 2001,

USA [28]

Cross-sectional survey, survey

completed in waiting room, 410

patients of which 101 overweight

and 105 obese, 89% response.

W: 24% of overweight patients had discussed weight with their

current doctor.

Low

W: 49% of obese patients had discussed weight with their current

doctor.

W: 64% of overweight patients said the most common weight loss

approach physicians used was not bringing up their weight.

W: 48% of obese patients said the most common weight loss

approach was telling patients to lose weight.

W: 33% of obese patients said not bringing up the subject of their

weight was the second most common weight loss approach.

W: 31% of obese patients reported a discussion of the health risks

of obesity.

N: 27% of obese patients reported dietary advice.

PA: 30% of obese patients reported exercise recommendations.



Author, year,

country, reference


Eaton et al., 2002,

USA [36]

Cross-sectional study, direct

observation of 3475 consecutive

outpatient visits of 138 family

physicians, patient and physician

questionnaire, medical record audit

and billing diagnosis, 26% response.

N: nutrition counseling occurred in 33% of visits in obese patients. Medium

Fogelman et al., 2002,

Israel [64]

Cross-sectional survey,

questionnaire distributed during

CME session, 510 family physicians,

82% response.

W: 4% advised weight reduction medication. Low

W: 38% advised behavioral treatment.

W: 25% advised group support meetings.

N: 81% advised to reduce total daily calories.

N: 61% advised to eat less ‘in general’.

N: 58% advised referral to dietitian advice.

N: 41% advised diet counseling by family physician.

PA: 95% advised to increase physical activity.

Brotons et al., 2003,

ten European

countries [65]

Cross-sectional surveys, mail

questionnaire and e-mail

questionnaire, Croatia, Estonia,

Georgia, Ireland, Malta, Poland,

Slovakia, Slovenia, Spain, Sweden,

1976 GPs and 15 GPs representing

national colleges (delegates), 50%

response.

W: 45% reported estimated BMI. Medium

W: 60% reported advising overweight patients to lose weight.

N: 10 out of 15 delegates reported that they GPs use some

nutritional/dietary recommendations.

N: 10 out of 15 delegates reported that they provide their patients

with special written dietary recommendations (e.g. a diet that

contains 1500 kcal/day, or 2000 kcal/day).

N: 5 out of 15 delegates reported that they can refer their patients

to trained nutrition specialists.

Scott et al., 2004,

USA [12]


observation and chart review, 633

encounters in 18 family practices.

W: talk about excess weight occurred in 17% of encounters with

overweight and obese patients.

Low

W: counseling was done in 11% of encounters with overweight

patients.

W: they discussed medication.

W: they looked at patient’s chart for weight gain.

N: they discussed diet.

N: they discussed referral to a nutritionist.

N: they ask patients to keep a food diary.

N: they discussed decreasing calories.

PA: they discussed increasing exercise.

The Counterweight

Project Team, 2004,

UK [29]

Cross-sectional survey, structured

interview, written questionnaire,

and audit of obese patients’ record,

141 GPs (and 66 practice nurses)

from 40 primary care practices, 78%

response.

W: 83% raised weight as an issue, encouraged and motivated and

spent 2 min or less.

Medium

W: 36% raised weight as an issue, provided supporting literature

and spent 2–5 min.

W: 15% raised weight as an issue, completed patient assessment,

provided supporting literature and spent 5–10 min.

W: 8% completed patient assessment, provided supporting

literature, personalized goal setting and spent more than 10 min.

W: 2% of obese patients’ records included anti-obesity medication.

N: 13% provided an individualized dietary prescription based on

calculated energy needs and spent more than 10 min.

N: 78% referred to practice nurse.

N: 58% referred to dietician.

N: 20% of obese patients’ records included diet counseling.

N: 4% of obese patients’ records included dietetic referrals.

PA: 50% provided an exercise prescription.

PA: 41% referred to commercial weight loss agency.

PA: 1% of obese patients’ records included obesity center referrals.

Bocquier et al., 2005,

France [23]

Cross-sectional representative

survey, computer-assisted

telephone interview, 600 GPs, 56%

response.

W: 89% often or always used BMI as diagnostic method. High

W: 66% often or always provided leaflets on healthy behavior.

W: 51% set a loss of 5–15% of initial weight as objective for

overweight patients.

W: 49% often or always included a spouse or close relative in

management.

W: 32% often or always recommended psychotherapy.

W: 23% often or always prescribed drug treatment.

W: 15% often or always recommended a behavioral therapy.

N: 100% often or always advised to consume fewer caloric drinks.

N: 98% often or always advised to eat less fat.

N: 96% often or always advised to eat more fruits and vegetables.

N: 95% often or always advised to eat less sugar.

N: 91% often or always advised not to eat between meals.

N: 76% often or always advised to eat less during meals.

N: 74$ often or always advised to follow personalized low-calorie

diet.

N: 64% often or always provided nutritional education.

N: 38% often or always provided a food diary.

N: 35% often or always advised to definitely avoid specific foods.

N: 22% often or always advised to follow very-low-calorie diet.

N: 12% often or always advised to follow commercial diet.

N: 31% often or always referred to a dietician.



Author, year,

country, reference


PA: 95% often or always advised to do more exercise in everyday

life.

PA: 87% often or always advised to exercise (sports).

Epstein and Ogden,

2005, UK [66]

Cross-sectional study, qualitative

study, in-depth semi-structured

interview, 21 GPs.

W: they offered anti-obesity drugs. Low

W: they discussed the psychological approach.

N: they advised patients on diet.

PA: they offered suggestions for behavior change of exercise.

PA: they referred to physiotherapy.

PA: they referred to the chiropodist.

Flocke et al., 2005,

USA [22]


observation, 300 family medicine

outpatient visits representing 13

physicians at eight practice sites.

W: weight loss was discussed in 33% of visits. High

W: asking about health behavior was observed in 27% of weight

loss discussions.

W: assessing patients’ readiness to change occurred in 2% of

weight loss discussions.

W: advice was observed in 80% of weight loss discussions.

W: assistance was observed in 14% of weight loss discussions.

W: follow-up was arranged in 3% of weight loss discussions.

W: 71% of weight loss discussions initiated by physicians

concerned advice (and assistance).

N: diet was discussed in 31% of visits.

N: asking about health behavior was observed in 53% of diet

discussions.

N: assessing patients’ readiness to change occurred in 9% of diet

discussions.

N: advice was observed in 87% of diet discussions.

N: assistance was observed in 17% of diet discussions.

N: follow-up was arranged in 10% of diet discussions.

N: 64% of diet discussions initiated by physicians concerned

advice (and assistance).

PA: exercise was discussed in 45% of visits.

PA: asking about health behavior was observed in 52% of exercise

discussions.

PA: assessing patients’ readiness to change occurred in 10% of

exercise discussions.

PA: advice was observed in 94% of exercise discussions.

PA: assistance was observed in 14% of exercise discussions.

PA: follow-up was arranged in 4% of exercise discussions.

PA: 74% of exercise discussions initiated by physicians concerned

advice (and assistance).

Nicholas et al., 2005,

Australia [67]



response.

N: 45% strongly agreed to usually provide nutrition in the

management of overweight.

Medium

N: 68% strongly agreed to usually provide nutrition in the

management of obesity.

Simkin-Silverman et al.,

2005, USA [33]

Cross-sectional survey, patient

questionnaire and medical record,

255 patients, of which 168 had been

previously told they were

overweight by 18 PCPs.

W: 32% of overweight patients received specific advice from their

PCP.

Low

W: 28% of patients with obesity classification I received advice

from their PCP.

W: 46% of patients with obesity classification II received advice

from their PCP.

W: 48% of patients with obesity classification III received advice

from their PCP.

W: 83% of patients who had been previously told they were

overweight reported that their PCP discussed health benefits of

weight loss.

W: 45% of told overweight patients reported that their PCP gave

advice to lose weight.


weight control referral.


weight control medication.

W: PCPs documented obesity in only 47% of patients medical

records.

W + PA: PCPs had discussed weight or exercise at an average of 33%

of previous appointments.

W + PA: PCPs had never discussed weight or exercise with 24% of

participants.

PA: 36% of told overweight patients reported that their PCP gave

advice to increase exercise level.

Thuan and Avignon,

2005, France [49]

Cross-sectional survey, mail survey,

607 GPs, 83% response.

W: 71% usually reviewed their patients’ progress frequently

(every 3–6 weeks) for the first few months.

High

W: 51% usually remained involved in the assessment of their

patients’ progress when he is referred to another health

professional.

W: 44% usually reviewed their patients’ progress for several years.

W: 40% usually referred the patient to a psychologist or a

psychiatrist when psychological problems are at the forefront.



Author, year,

country, reference


W: 24% usually saw patients together with a spouse or other.

N: 62% usually evaluated and treated eating disorders.

N: 43% usually referred the patient to a nutrition specialist.

N: 30% usually referred the patient to a dietician.

N: 94% usually gave advices to reduce overall caloric intake.

N: 94% usually gave advices to reduce caloric drinks.

N: 94% usually gave advices to reduce alcohol intake.

N: 94% usually gave advices to reduce nibbling.

N: 70% usually gave advices to eat less fat.

N: 57% usually prescribed a low-calorie diet.

N: 38% usually gave advices regarding shopping and cooking.

N: 30% usually gave advices to keep an eating awareness diary.

PA: 94% usually gave advices to incorporate low-intensity activity

into lifestyle.

PA: 70% usually gave advices to perform sport activities two to

three times a week.

Van Dillen et al., 2005,

The Netherlands [41]


questionnaire, 267 family doctors,

45% response.

W: if they communicate about overweight, the majority would

choose the confrontational style.

High

W: if they communicate about overweight, the motivational style

was also used.

N: 73% always discussed nutrition when dealing with the health

problem overweight/obesity.

Douglas et al., 2006,

UK [44]


questionnaire, 376 GPs (and 212

practice nurses and 160 health

visitors), 47% response.

PA: 60% always provided physical activity advice to overweight

patients.

High

Klumbiene et al.,

2006, Lithuania [68]

Cross-sectional representative

survey, postal surveys of 2000, 2002

and 2004, 2049 overweight and

obese persons, 74% response in

2000, 63% response in 2002, 62%

response in 2004.

N: 19% of overweight patients received advice to change dietary

habits.

Medium

N: 36% of obese patients received advice to change dietary habits.

N: 53% of severe obese patients (BMI � 35) received advice to

change dietary habits.

PA: 9% of overweight patients received advice to increase physical

activity.

PA: 28% of obese patients received advice to increase physical

activity.

PA: 52% of severe obese patients received advice to increase

physical activity.

Boardley et al., 2007,

USA [32]

Cross-sectional study, observational

study, 405 adult patients, of which

32% overweight patients, 38% obese

patients and 7% morbidly obese

patients (and 148 children) in two

large family medicine practices.

W: BMI was calculated in 63% of well visit. Low

W: 30% of overweight patients received minimal weight education.

W: 8% of overweight patients received detailed weight education.

W: 43% of obese patients received minimal weight education.

W: 12% of obese patients received detailed weight education.

W: 45% of morbidly obese patients received weight education.

W; 17% of morbidly obese patients received weight education.

N: 34% of overweight patients received minimal diet education.

N: 10% of overweight patients received detailed diet education.

N: 44% of obese patients received minimal diet education.

N: 10% of obese patients received detailed diet education.

N: 31% of morbidly obese patients received minimal diet

education.

N: 28% of morbidly obese patients received detailed diet

education.

PA: 28% of overweight patients received minimal exercise

education.

PA: 7% of overweight patients received detailed exercise education.

PA: 38% of obese patients received minimal exercise education.

PA: 7% of obese patients received detailed exercise education.

PA: 31% of morbidly obese patients received minimal exercise

education.

PA: 14% of morbidly obese patients received detailed exercise

education.

McAlpine and Wilson,

2007, USA [17]

Longitudinal study, national survey

of visits to office-based PCPs from

1995 through 2004, in 2004 1372

physicians recorded 25,286 office

visits, response ranged from 63% to

73%.

W: counseling for weight loss occurred in 9% of visits to PCPs in

1995/1996.

Medium

W: counseling for weight loss occurred in 6% of visits in 2003/2004.

N: diet and nutrition counseling occurred in 20% of visits in 1995/

1996.

N: diet and nutrition counseling occurred in 20% of visits in 2003/

2004.

PA: counseling about exercise occurred in 5% of visits in 1995/1996.

PA: counseling about exercise occurred in 14% of visits in 2003/

2004.

W + N + PA: the percentage of visits that received any of these

types of counseling was 25% in 1995/1996.

W + N + PA: the percentage of visits that received any of these

types of counseling was 24% in 2003/2004.



Author, year,

country, reference


Peytremann-Bridevaux

and Santos-Eggiman,

2007, ten European

countries [69]


questionnaire, Austria, Denmark,

France, Germany, Greece, Italy, the

Netherlands, Spain, Sweden,

Switzerland, 13,859 patients of

which 6043 overweight patients

and 2451 obese patients, 51%

response.

W: 57% of overweight persons had their weight checked by their

GP at least once.

Medium

W: 70% of obese persons had their weight checked by their GP at

least once.

PA: 58% of overweight persons reported that their GP ever asked

about physical activity.

PA: 61% of obese persons reported that their GP ever asked about

physical activity.

PA: 53% of overweight persons reported that their GP ever

recommended physical activity.

PA: 62% of obese persons reported that their GP ever

recommended physical activity.

Greiner et al., 2008,

USA [18]

Cross-sectional survey, post-visit

patient survey and post-visit

physician survey, 456 obese

patients and 30 physicians of 29

primary care practices.

W: physicians reported that in 60% of office visits discussions

about weight occurred, against 52% reported by patients.

Low

W: 18% of physicians reported never discussing weight with obese

patients, against 33% reported by patients.

N: physicians reported that in 52% of office visits discussions about

nutrition/diet occurred, against 38% reported by patients.

PA: physicians reported that in 56% of office visits discussions

about physical activity occurred, against 44% reported by patients.

Al-Ghawi and Uauy,

2009, Bahrain [45]

Cross-sectional survey, self-

administered questionnaire, 97

primary health care physicians, 90%

response.

W: 71% weighed patients as part of chronic disease care most of

the time.

High

W: 33% screened their patients for weight problems most of the

time.

W: 64% used behavioral counseling most of the time.

W: 58% used leaflets and educational material most of the time.

W: 40% involved the patient’s family most of the time.

W: 5% used pharmacotherapy most of the time.

W: 3% referred to weight-loss surgery most of the time.

N: 98% advised patients on diet most of the time.

N: 41% referred patients to dieticians most of the time.

PA: 96% advised patients on physical activity most of the time.

Ampt et al., 2009,

Australia [42]

Cross-sectional study, qualitative

interviews, 15 GPs (and one practice

nurse).

N: they only assessed diet if the patient was overweight. Low

N: they provided a higher amount of diet advice to overweight

patients.

N: they only followed up if the patient was already overweight.

N: they referred to dieticians for nutritional advice if the patient is

overweight.

PA: they only assessed physical activity if the patient was

overweight.

PA: they provided a higher amount of physical activity advice to


PA: they only followed up physical activity if the patient was

already overweight.

Eley and Eley, 2009,

Australia [70]

Cross-sectional study, pilot study,

mail survey, 27 GPs, 68% response.

W: 100% stated that their primary strategy used to address

overweight was discussion and advice.

Medium

PA: 4% reported setting an example in the community by

exercising regularly.

PA: 59% referred patients to local gyms or fitness classes.

PA: 56% referred patients to allied health professionals and local

sport/recreation organizations.

PA: 22% referred patients to exercise physiologists and/or

physiotherapists.

Ferrante et al., 2009,

USA [71]


questionnaire, 255 family

physicians of extremely obese

patients, 53% response.

W: they sometimes recommended to focus on improving health,

not weight loss.

High

W: they sometimes recommended bariatric surgery.

W: they infrequent recommended weight loss drugs.

N: they almost always recommended basic good nutrition/adding

fruits and vegetables.

N: they frequent recommended low fat diet.

N: they frequent recommended referral to nutritionist.

N: they frequent recommended no specific diet, just calorie

reduction.

N: they infrequent recommended South Beach diet.

N: they infrequent recommended Atkins diet.

PA: they almost always recommended regular exercise.

PA: they frequent recommended Weight Watchers or other

commercial program.

Phelan et al., 2009,

USA [21]


questionnaire, 101 family

physicians and internists (48%

family physicians, 37% internists,

16% other), 54% response.

W: 76% reported always or nearly always addressing weight

control issues with overweight and obese patients (Likert-scale,

1 = never and 7 = always).

Medium

W: they sometimes recommended to weigh themselves regularly.

W: they sometimes provided in-office educational materials.

W: they rarely recommended Internet sources for weight loss.

W: they rarely advised to use weight loss medication.

N: they always recommended to reduce consumption of fast food.



Author, year,

country, reference


N: they almost always recommended to reduce portion sizes.

N: they almost always recommended to reduce soda

consumption.

N: they almost always recommended to eat a low-caloric diet.

N: they often recommended to decrease the fat content of diet.

N: they often recommended to consume breakfast.

N: they sometimes referred to a dietitian for individual

counseling.

N: they sometimes recommended to use fat and/or calorie

modified foods.

N: they sometimes followed a specific calorie goal.

N: they sometimes recommended to eat a modified low-

carbohydrate diet.

N: they sometimes recommended to record food intake in a diary.

N: they seldom recommended to eat a Mediterranean diet.

N: they seldom recommended to eat a low-carbohydrate diet.

N: they rarely advised to use meal replacements.

PA: they always recommended to increase physical activity.

PA: they almost always suggest a specific type of physical activity.

PA: they often recommended a specific intensity of physical

activity.

PA: they often recommended locations to which individuals can

go to engage in physical activity.

PA: they sometimes referred to a commercial program.

PA: they sometimes recommended to decrease television viewing.

PA: they rarely referred to an exercise specialist.

Waring et al., 2009,

USA [72]

Cross-sectional study, computer-

assisted telephone interview and

medical record in the previous two

years, 2330 overweight or obese

primary care patients from 30

primary care practices, 55%

response.

W: 45% of patients with documented overweight received advice

to lose weight.

Medium

W: 49% of patients with documented mild obesity (30 � BMI � 35)

received advice to lose weight.

W: 65% of patients with documented moderate/severe obesity

(BMI � 35) received advice to lose weight.

N: 76% of patients with documented overweight received diet

recommendations.

N: 76% of patients with documented mild obesity received diet

recommendations.

N: 77% of patients with moderate/severe obesity received diet

recommendations.

N: 19% of patients with documented overweight received referrals

for nutrition counseling.

N: 19% of patients with documented mild obesity received

referrals for nutrition counseling.

N: 25% of patients with documented moderate/severe obesity

received referrals for nutrition counseling.

PA: 61% of patients with documented overweight received

physical activity recommendations.

PA: 59% of patients with documented mild obesity received

physical activity recommendations.

PA: 62% of patients with documented moderate/severe obesity

received physical activity recommendations.

Booth and Nowson,

2010, Australia [20]

Cross-sectional survey, face-to-face

survey, 2947 patients of which 955

overweight patients and 578 obese

patients, 63% response.

W: 27% of overweight/obese patients reported receiving lifestyle

advice for weight loss purposes in the past 12 months from their

GP.

Medium

W: 3% of overweight patients reported being referred elsewhere.

W: 11% of obese patients reported being referred elsewhere.

N: 4% of overweight patients reported receiving only dietary

advice.

N: 9% of obese patients reported receiving only dietary advice.

PA: 5% of overweight patients reported receiving only exercise

advice.

PA: 9% of obese patients reported receiving only exercise advice.

N + PA: 9% of overweight patients reported receiving diet plus

exercise advice.

N + PA: 26% of obese patients reported receiving diet plus exercise

advice.

Denney-Wilson et al.,

2010, Australia [24]

Cross-sectional study,

questionnaire, 90 GPs.

W: 47% usually or always set a goal for weight loss for overweight

or obese patients.

Low

W: 6% usually or always prescribed new medications to

overweight or obese patients.

N: 68% advised less dietary fat to overweight or obese patients.

N: 51% usually or always recommended fewer calories to


PA: 72% usually or always advised regular exercise to overweight

or obese patients.



Author, year,

country, reference


Heintze et al., 2010,

Germany [25]

Cross-sectional study, observation,

52 final therapeutic routine

consultations of 12 GPs with


W: GPs and patients rarely agree on weight loss goals. Medium

N: dietary advice was the most important topic for GPs in the talks.

N: they recommended different methods, namely food diary,

leaflets, internet links or nutrition guidelines/schedules, eating

less, reducing daily calories, attaching importance to certain foods.

N: they recommended an external nutritional training course or

dietician.

PA: physical activity was the second most important topic for GPs

in the talks.

PA: they tended to give more general advice on increasing physical

activity without providing detailed strategies.

PA: they stressed the importance of individual preferences in

reinforcing the commitment to increased physical activity.

PA: they recommended the Weight Watchers.

Passey et al., 2010,

Australia [27]


questionnaire, 50 GPs (and 13

practice nurses) in 30 practices.

W: 59% often, usually or always set a goal for weight loss. Medium

W: 19% often, usually or always prescribed new medications.

N: 70% often, usually or always provided advice about diet to

patients with lifestyle risk factors.

N: 78% often, usually or always advised less dietary fat.

N: 65% often, usually or always recommended less calories.

PA: 91% often, usually or always provided advice about exercise to

patients with lifestyle risk factors.

PA: 91% often, usually or always advised regular exercise.

Huber et al., 2011,

Switzerland [34]



response.

W: 20% regularly measured waist circumference. High

W: 9% regularly clarified interest and willingness to improve the

health status by (support) groups.

N: 64% regularly gave general advice to reduce energy intake.

N: 56% regularly provided individual consultation to reduce the

consumption of alcohol and high caloric drinks.

N: 54% gave specific information to reduce lipid intake.

N: 35% gave specific information about carbohydrate and proteins.

N: 20% urged the patient to use a food diary for 1 week.

N: 12% gave practical instruction for buying food.

N: 8% gave practical instructions for cooking.

PA: 78% gave general advice to increase physical activity in daily

life (e.g. walking instead of driving by car).

PA: 66% gave advice to do exercises 2–3 times a week (e.g. jogging,

swimming).

Pickett-Blakely et al.,

2011, USA [37]

Cross-sectional study, clinical

encounters of 5667 obese patients

and their physicians from general

practice and internal medicine.

W: weight reduction counseling was provided to 20% of obese

patients.

Medium

N: diet/nutrition counseling was provided to 30% of obese

patients.

PA: exercise counseling was provided to 23% of obese patients.

Pollak et al., 2011,

USA [40]

Cross-sectional study, observational

study, audio records and

questionnaire, 40 PCPs and 461


W: BMI/weight was addressed in 73% of encounters. Medium

W: mean time spent discussing BMI/weight was 42.1 s.

W: total weight-related time was 200.1 s.

W: 69% counseled using motivational interviewing.

W: 27% used any open questions.

W: 25% used any simple reflections.

W: 5% used any complex questions.

W: they showed low scores on spirit and empathy.

N: nutrition was addressed in 78% of encounters.

N: mean time spent discussing nutrition was 85.4 s.

PA: physical activity was addressed in 82% of encounters.

PA: mean time spent discussing physical activity was 57.0 s.

Wilder Smith et al.,

2011, USA [73]

Cross-sectional nationally

representative survey, mail

questionnaire, 1211 primary care

physicians (from which 388 with

the specialty family practice), 64%

response.

W: 55% recorded BMI regularly. High

W: 44% never measured weight by patient self-report.

W: 56% never measured waist circumference.

N: 72% asked general questions about dietary patterns.

N: 68% asked general questions about food groups.

N: 51% asked specific questions about diet components.

N: 13% used other (written in) assessment.

N: 12% used a standardized diet questionnaire.

N: 6% did not assess diet.

PA: 77% asked general questions about amount of physical

activity.

PA: 71% asked specific questions about duration, intensity, and

type of physical activity.

PA: 7% used a standardized physical activity questionnaire.

PA: 4% used other (written in) assessment.

PA: 2% did not assess physical activity.

W: weight guidance practices; N: nutrition guidance practices; PA: physical activity guidance practices.



other studies, the range of communication strategies for nutritionalso showed to be even more diverse than for physical activity.

3.6. Analysis on the basis of the theoretical framework 5A’s

We found only one study [22] in which the use of the 5A’sModel to discuss nutrition, physical activity and weight loss ingeneral practice was explored. Therefore, we screened all studieson these five components, and found that most studies reportedabout Advise. Advise was not very specific however. We foundthat general advice about nutrition or physical activity was morecommon than specific advice about nutrition or physical activity.After Advise, Arrange seems to be the most important compo-nent. Referral scores to other health professionals were muchlower than frequencies about advice. Referrals made todieticians were most common. Moreover, GPs rarely assistedtheir patients with diets (e.g. low-caloric diet). Furthermore,Agree was seldom a component. There were only a few studies,in which agreement about goals was discussed. We found thatnine studies incorporated all five components of the 5A’s Model[21,23–29], but only Flocke et al. [22] mentioned the model intheir article.

3.7. Study quality

On average, studies in this review were assigned six plusses.Twelve studies were considered as high-quality studies, 18 studieswere perceived as medium quality, and 11 studies were seen aslow quality. Almost all studies had a clear description of study aim,suitable report of study limitations and shortcomings, and anappropriate size of study population. However, the majority of thestudies were not representative. Only half of the studies had a goodresponse rate and did not report about efforts undertaken tooptimize response rate. Moreover, measurement instrument wasoften not well-developed or appropriate. We also judged theselection of the study population for the majority of studies not besound.

We found that study quality was higher for the studiesperformed in the last five years possibly due to growingunderstanding. It appeared that outcomes were the same forstudies performed before and after 2006.

4. Discussion and conclusion

4.1. Discussion

First, we elaborated upon the content of advice about nutritionand physical activity, which was quite general. A common advicewas ‘‘increase physical activity’’. Although there were a lot ofdifferent approaches to obesity management, it seems like GPsonly used a few. Obese patients reported a variety of interventions,but all frequencies showed to be lower than 20% [28]. In anotherstudy, almost 50% of obese patients reported that their GP had notrecommended any of ten common weight loss interventions, 22%had prescribed one intervention and 17% two interventions [30].GPs routinely reported a high number of weight discussions duringvisits than patients reported [18]. Recently, a study showed thatpatients tended to forget instructions provided by their GP.Therefore, one or two instructions in a consultation seems to beappropriate. When more advice is needed, the follow-up should bewithin the next 14 days [31]. Boardley et al. [32] distinguished thelevel of instruction into none (e.g. no indication of discussion orplan in chart), minimal (e.g. general comments) and detailed (e.g.documentation of specific goals or educational plan), resulting inthe highest scores for the lowest level of instruction. Actually anystrategy that would help patients and GPs frame weight as a

problem is likely to increase the frequency of weight losscounseling [12]. GPs’ decisions to advice patients may be guidedby quick but fallible heuristics, rather than more thorough andaccurate – if more time-consuming – behavioral assessments [19].Nutritional management often seems limited to one-shot adviceprovided by the GP themselves instead of referring to the dietician,and neglects tools that could help induce long-term behaviormodifications [24]. Overweight and obese patients preferred thatGPs provide direct and specific information on nutrition and diet,setting weight-loss goals, and exercise plans [19]. However,patients were more likely to receive education about weight lossthan specific behavioral advice on how to lose weight from theirGPs [33]. Only a minority of GPs reported to give detailedinstructions for cooking and buying food as recommended inseveral guidelines [34].

Furthermore, we reflected on the fact that quality of guidancepractices was hardly studied. Most studies focused on the quantityof GPs’ guidance practices in order to prevent or treat overweightor obesity and discussed the frequency that each approach ormethod was used, reporting rather low frequency rates. Thefrequency of GPs providing counseling for nutrition, physicalactivity and weight loss is much less than might be expected by thehigh prevalence of weight problems [17]. A study around SNAP riskfactors (that is smoking, nutrition, alcohol use and physicalactivity) showed that more than twice as many GPs routinelyassessed and offered advice for smoking and alcohol than for dietand physical activity [24]. However, most studies did not yet takeinto account the quality of the advice given. Practical advice givenby GPs to patients on how to set about losing weight had beengenerally poor [35]. Another study concluded that the content ofthe advice rarely includes recommended components that couldincrease healthy behavior change [22]. Others only reported thatdetails on the content of (weight control) counseling or advicegiven to patients were lacking [33,36,37]. According to Glanz [38],there are several conditions that contribute to the quality ofcommunication between health professionals and patients,namely assessment of patients’ motivation and potential barriersand supporting factors, use of goal setting, and provision ofindividually targeted information. We summarize that especiallyassessment of patients’ barriers and supporting factors seem to behardly reported in the selected studies. Moreover, only a fewstudies reported targeting information to the specific situation ofthe patients. The above-mentioned conditions are more or lessincorporated in motivational interviewing. According to Emmonsand Rollnick [39], motivational interviewing includes reflectingback to patients, praising patients for even small changes, allowingpatients to set their own goals, asking permission before givingadvice, accepting patients’ motivation to change, and workingcollaboratively as the patients attempt to change. In only one of theselected studies, use of motivational interviewing was actuallymentioned [40]. If GPs communicate about overweight, they used aconfrontational or motivational style [41]. Moreover, we foundthat Agree (about goals) was the least applied component of the5A’s Model in the selected studies. However, in one of the studies,GPs rarely agreed on weight loss goals during the consultations[25]. GPs who recognized that success for weight reductionincludes small weight losses voiced less frustration than thosewhose measure of success was the achievement of ideal weightgoals [42]. Over 60% of GPs set even stricter weight loss objectivesfor obese patients than recommended [23]. Apparently, GPs werenot eager to collaboratively select appropriate treatment goals andmethods based on patient’s willingness to change the behavior.However, this so-called goal setting might be important to achievelong-term behavioral change. Additionally, several guidelinesabout nutrition [3–5], physical activity [6–8] and obesity [13–15] have been developed so far to improve the quality of lifestyle


counseling. The studies of Bocquier et al. [23] and Huber et al. [34]were the only ones, which reported that GPs’ practices follow theguidelines relatively closely. In other studies, it remains unclear ifGPs adhere to the current guidelines. Furthermore, a few studieslooked at the duration of counseling [29,36,40]. Nevertheless, GPsspent less time than the 8 min recommended to help patientschange nutrition behaviors [40].

Next, we want to reflect on the fact that GPs still took atherapeutic approach toward weight problems. Some advices wereprovided as a single advice specifically focused on overweight orobesity, while other advices were provided within the curativecontext of the patients, for example for co-morbidities of type 2diabetes or hypertension. GPs spent most of their time ontreatment [43]. Weight guidance occurred more often amongobese patients than overweight patients. For example, 53% ofoverweight patients did not receive any advice about diet, exerciseor weight loss, while 35% of obese patients did not receive anyadvice [22]. Patients with higher body mass indices were morelikely to have had discussions about nutrition or physical activitywith their GPs [28]. Having a high body mass index was even thestrongest predictor of receiving advice to increase physical activity[19]. GPs were even more likely to always provide physical activityadvice for overweight patients than for any other medicalcondition [44]. Another study showed that patients with five ormore risks were three times as likely to receive advice to eat less fatand also to increase physical activity as those with no risks [19].GPs more often identified weight problems as part of chronicdisease care than for screening purposes [45]. Another possibleexplanation for their trust on a therapeutic rather than preventiveapproach toward weight problems is that GPs substantiallyunderestimated the prevalence of overweight and overestimatedthat of obesity [24]. Patients with therapeutic needs were twice aslikely to be advised to reduce dietary fat consumption as thosewith only preventive needs. If counseling to reduce behavioralrisks is more motivated by therapeutic than preventive interests,GPs consistently miss opportunities for primary prevention amongat-risk patients, next to obese patients [19]. Recently, a reviewshowed that although consultations provide an ideal setting forpreventing illnesses, general practice focuses primarily onsecondary prevention [46]. A recent study showed that thepredictive models for different guidance practices contained bothprevention and treatment elements [47]. GPs’ guidance practicesare strongly influenced by their task perception. Both Australianand French GPs hold strong positive views about their responsi-bilities in the area of obesity management [24,48,49]. In themajority of encounters with overweight patients, weight wasmentioned by neither patient nor GP, even for those patients whowere visibly obese and who were being treated for acute or chronicconditions [12]. Nearly 85% of GPs stated that they would provideadvice about weight loss even if the patient had not requested it[45]. In the past decade however, GPs’ provision of unsolicitedadvice about overweight has gained a wider support among bothGPs and patients [50].

Finally, we want to reflect on the findings that GPs’ provision ofcombined lifestyle advice to overweight and obese patients seemsto be rather low. To our knowledge, this is the first critical reviewwith a focus on the combination of GPs’ communication strategiesrelated to nutrition and physical activity to reduce weight. Thecombination of advice for nutrition and physical activity wasspecifically asked for in only two studies [19,20]. In most otherstudies, both nutrition and physical activity advice were reported,but it remains unclear whether they were offered in the sameconsultation. Recently, a study showed that the majority of GPsdemonstrated shared practices for nutrition and physical activityguidance [47]. The current Dutch guideline for the identificationand management of obesity mentioned a combined lifestyle

intervention (nutrition, physical activity and behavioral change) asthe first choice for treatment of obese patients [13]. The mainoutcome of the combined lifestyle intervention is stabilization ofthe reached body weight over years. The effects of combinedlifestyle interventions were nevertheless small, even in random-ized trial settings. There is an urgent need for a combined lifestyleintervention, developed and shown to be effective in real-worldprimary care [51]. Not only individual treatment, but alsoenvironmental interventions are important [38,52,53].

4.2. Conclusion

Our review indicated that most GPs provide rather generaladvice about nutrition or physical activity. We also reflected on thefact that studies about the quantity of guidance practices weremore common than quality. Furthermore, it seems like GPs stilltook a therapeutic approach toward weight problems. Finally, werevealed that the provision of combined lifestyle advice by GPsseems to be relatively low.

4.3. Practice implications

Observational research is needed to unravel the quality of theadvice given by GPs to overweight and obese patients, in particularfor the combined lifestyle intervention within the light ofuniversal, selective and cure/care-related prevention for thespecified diagnosis. Longitudinal data should be collected tounderstand in greater detail how weight is discussed. Futureresearch should also look closer at the combination of nutritionand physical activity advice provided in the interaction betweenGPs and their overweight or obese patients. Previous researchshowed that GPs and patients still have different perspectives onnutrition communication [54]. It is interesting to look into depth atthe development process of agreement between GPs and patientswith respect to weight loss goals and approaches. Implementationintentions may be useful to help patients in translating their goalsinto action [55]. More specifically, assessing readiness to changebefore offering advice or suggestions may yield improved resultsfrom lifestyle counseling [24]. Comprehensive reviews concludedthat effective nutrition interventions are behaviorally focused, andaddress personal relevant motivators [56,57]. Determinants ofnutrition guidance, including predisposing factors (such as self-efficacy), driving forces (such as task perception), and perceivedbarriers, have been studied [41,58]. Lack of patient motivation, lackof time and lack of knowledge or skills were reported by GPsthemselves as perceived barriers to overweight treatment [59].Furthermore, GPs should more often discuss both potentialbarriers as well as supporting factors for nutrition and physicalactivity with their patients. Evidence suggests that there areopportunities presenting to GPs that are possibly being missed[60]. Practical tools, such as a minimal intervention strategyaddressing overweight and obesity, seem to be useful [61].

Conflict of interest

The authors declare that there are no conflicts of interest.

Acknowledgement

This research was supported by the Dutch Dairy Association.

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Nutrition and physical activity guidance practices in general practice: A critical review

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