Physicians’ Discussions About Body Weight,Healthy Diet,and Physical Activity With Overweight or Obese Elderly Patients

Abstract

Objective: To investigate the correlates of physician–patient discussions about body weight, healthy diet, and physical activity. Method: Subjects were 635 adults (≥65 years; mean 72.8 years) who had an increased body mass index (BMI≥25kg/m²) and participated in a self-administered community survey. Logistic regression analyses were performed. Results: While approximately half of study participants reported having discussed healthy diets (51%) and physical activity (52%) with their physician, only 42% of those who were overweight or obese reported being recognized as such by their physician. Being moderately or severely obese, more chronic conditions, and more frequent physician visits increased the likelihood of being recognized as overweight or obese and reporting lifestyle discussions. Discussion: The health care provider is important in recognizing older patient’s weight problems and discussing practical lifestyle changes. Tools for more proactive screening and implementation of follow-up behavioral counseling can help the health care providers better address obesity prevention in clinical practice.

Keywords

physician–patient encounter obesity healthy diet physical activity

Introduction

Recent estimates show that obesity affected 33% of females and 37% of males aged 60 years or older in the United States (Ford, Li, Zhao, & Tsai, 2010). With aging, fat is redistributed and increasingly infiltrates tissues such as pancreas, muscle, and bone (Duque & Kuchel, 2010). Some studies identified the “obesity paradox” in which overweight and obese older adults were actually likely to have better health outcomes than their normal-weight counterparts (Diehr et al., 2008; Oreopoulos, Kalantar-Zadeh, Sharma, & Fonarow, 2009). Nevertheless, there is a public health concern that as the baby boomers age they are reaching their sixth decade heavier than previous generations and that overweight adults are at risk for becoming obese (Flegal, Carroll, Ogden, & Curtin, 2010). Among older adults, obesity is associated with adverse health outcomes including increased morbidity (Ahn, Sharkey, Smith, Ory, & Phillips, 2011; Harrington & Lee-Chiong, 2009) and dementia risk (Fitzpatrick et al., 2009) as well as quality-adjusted life years (QALY) lost (Groessl, Kaplan, Barrett-Connor, & Ganiats, 2004). Without effective prevention interventions to halt this growing obesity epidemic, it is projected that 80% of American adults would be at risk for becoming overweight or obese by 2022 (Wang, Beydoun, Liang, Caballero, & Kumanyika, 2008).

Given older adults traditionally respect their doctors, health care providers are seen as potential agents who can influence lifestyle behavior modification among older patients with excess body weight (Gallo, Bogner, Morales, & Ford, 2005). For nearly a decade, the U.S. Preventive Services Task Force (USPSTF) has recommended that all clinicians screen their adult patients for obesity and offer behavioral interventions about healthy diets and physical activity during the visit to improve body composition (McTigue et al., 2003). As evidence for USPSTF recommendations, researchers have found moderate- or high-intensity counseling interventions can increase fruit and vegetable intake, and even brief counseling by primary care physicians is capable of producing small changes in dietary behaviors (Pignone et al., 2003). Newer guidelines underscore earlier Surgeon General’s guidelines that encourage health care providers to routinely talk to their adult patients about incorporating physical activity into their lives (National Center for Chronic Disease Prevention and Health Promotion, 1999). These newer guidelines emphasize the importance of maintaining a healthy weight and being more physically active throughout the life-course, which includes seniors who were often ignored in earlier research and practice recommendations (U.S. Department of Health Human Services, 2008).

Despite national guidelines, limited time is typically devoted to lifestyle discussions during physician–older adult interactions (Ory et al., 2006). One in-depth examination of physician–older adult interactions found that, on average, physical activity was discussed for less than a minute (58 s) and nutrition for less than 2 min (83 s) during a typical visit (Ory, Peck, Browning, & Forjuoh, 2007). Despite the importance of lifestyle changes among adults who are obese, little is known about how often health care providers discuss healthy diets and physical activity with their older patients who are overweight or obese. The purposes of this study are to (a) identify the percentage of health care providers having physician–older patient discussions about healthy diets and physical activity and patients’ recall about being told they were overweight or obese; (b) investigate factors associated with being recognized as overweight or obese and having discussions regarding healthy diets and physical activity; and (c) provide recommendations for improvement based on study findings.

Method

Data source and study population

A subset (n = 635) of data was analyzed from 3,946 adults who participated in the 2010 Brazos Valley Health Status Assessment survey. This survey was conducted to assess community health in an eight-county region and to identify vulnerable populations and modifiable health determinants. This survey utilized a standard random-digit dialing technique capable of producing a regionally representative sample of the noninstitutionalized civilian population of eight counties in Central Texas. After the initial telephone-based recruitment, paper-based surveys were mailed to those who agreed to participate in the study. Of those who could be reached by phone, 52% agreed to participate, and of those, 62% returned completed surveys (i.e., overall response rate = 32%). Based on the recruitment strategy described above, our study included 635 adults aged 65 years or older (mean = 72.8, standard deviation [SD] = 6.2), who had a self-reported body mass index (BMI) equal to or greater than 25kg/m² (mean = 30.4, SD = 4.8). To be included in our study, respondents must have answered survey items used to categorize dependent and independent variables of interest.

Measurements

Dependent Variables

Being recognized as overweight or obese

The first dependent variable was based on responses to the survey item, “Has a medical care provider (physician, nurse practitioner or physician assistant) ever told you that you had obesity or overweight: yes or no?” Respondents who gave positive answers to the question were classified as being recognized as overweight or obese by their health care provider.

Discussing healthy diets with health care provider

The second dependent variable was based on responses to the survey item, “If you visited a doctor, nurse, physician assistant or nurse practitioner in the past 2 years, did he or she talk with you about your diet and healthy eating: yes or no?” Respondents who gave positive answers to the question were classified as having discussed healthy diets with their health care provider.

Discussing physical activity with health care provider

The third dependent variable was based on responses to the survey item, “If you visited a doctor, nurse, physician assistant or nurse practitioner in the past 2 years, did he or she talk with you about your physical activity: yes or no?” Respondents who gave positive answers to the question were classified as having discussed physical activity with their health care provider.

Independent Variables

Demographic factors

We included race/ethnicity (non-Hispanic White, African American, Hispanic), age (65-74, ≥75 years), sex, and education (≤high school, >high school) to assess personal characteristics associated with the dependent variables.

Health status

Body mass index (BMI). The BMI was calculated from self-reported weight in kilograms divided by the square of self-reported height in meters and rounded to the nearest tenth as recommended by the original Quetelet calculation (Garrow & Webster, 1985). The BMI is categorized using the World Health Organization criteria with samples being classified as overweight (25.0-29.9 kg/m²), moderately obese (30.0-34.9 kg/m²), or severely obese (≥35 kg/m²; World Health Organization, 1998). All individuals with a BMI below 25 kg/m² were excluded from the study sample because of our focus on overweight and obesity.

Physical and mental health

Physical health was assessed by asking participants the average number of unhealthy physical days they experienced during the past 30 days (0 day, 1-7 days, ≥8 days). Physical health was further assessed by asking participants the number of physician-diagnosed health conditions (i.e., arthritis or other musculoskeletal problems, diabetes, mental illness, lung disease, and fractures or joint injuries; 0-1, 2, ≥3 conditions). Mental health was evaluated using the Patient Health Questionnaire-9 (PHQ-9; Gary, Stark, & LaVeist, 2007). The PHQ-9 scoring algorithm is described elsewhere (Kroenke, Spitzer, & Williams, 2001). The PHQ-9 total score ranges from 0 to 27 with five categories: no depression, mild, moderate, moderately severe, and severe (Monahan et al., 2009), which was dichotomized into no depression (0-4) or mild depression or higher (5-27) because of the distribution characteristics.

Health behaviors

Fast food consumption was assessed by asking the participants the frequency of eating fast food meals or snacks (never to 3 times a month, 1-2 times a week, ≥3 times a week). As another health behavioral factor, watching television was assessed by asking the respondents the frequency of watching television (or movies on television) in the past 30 days (<2 hr, 2-4 hr, >4 hr a day).

Health care utilization

Health care utilization was assessed by asking study participants about their outpatient care and routine check-ups with medical providers (Hunter et al., 2003). Outpatient care utilization was assessed by asking the participants the number of times they used a doctor’s office or clinic (all types of medical care) in the past 12 months (0-2, 3-4, ≥5 times). Routine check-up was assessed by asking the participants the last time they had a routine check-up (in the past year, more than the past year).

Analyses

Analyses were conducted with Stata 11 statistical software (StataCorp, 2009). To assess the potential relationships between study variables and three dependent variables, we performed both bivariate and multiple logistic regression analyses. Bivariate analyses were conducted to examine the associations of demographic factors, health status, health behaviors, and health care utilization with three dependent variables. Three separate logistic regression models were used to identify factors associated with each of the dependent variables. Log-likelihood ratio test was used to build these final models, and the Hosmer–Lemeshow test was used for goodness-of-fit assessment (Hosmer, Hosmer, Le Cessie, & Lemeshow, 1997). Odds ratios (OR) with 95% confidence intervals are displayed.

Results

Basic population characteristics

Approximately 57% (n = 362) of study participants self-reported being overweight, while 30% (n = 190) were moderately obese and 13% (n = 83) were severely obese (Table 1). About 42% (n = 267) of the participants whose self-reported BMI levels classified them as overweight or obese reported being recognized as overweight or obese by a health care provider. Among study participants, 51% (n = 321) and 52% (n = 330) reported having discussed healthy diets and physical activity with their health care provider, respectively. The study sample was predominantly non-Hispanic White (90%, n = 574), female (59%, n = 373), and college educated (58%, n = 369). Approximately 24% (n = 152) of participants reported feeling physically bad more than 7 of the past 30 days. More than 35% (n = 228) reported having more than 3 chronic conditions, which is known to lead to activity limitations. Sixty percent (n = 377) of participants reported having at least mild depression. About 15% (n = 92) of study participants reported eating fast food more than 3 times a week, and 33% (n = 209) reported watching television more than 4 hr on an average day. Around 40% (n = 254) of study participants reported visiting the doctor’s office or clinic more than 5 times in the past 12 months. Approximately 86% (n = 546) reported having a routine check-up in the past year.

Table 1.

Demographic Characteristics of Study Sample (n = 635)

Sample characteristics	% (n)
Recognized as overweight or obese
No	57.9 (368)
Yes	42.1 (267)
Discussed healthy diets with health care provider
No	49.5 (314)
Yes	50.6 (321)
Discussed physical activity with health care provider
No	48.0 (305)
Yes	51.9 (330)
Demographic factors
Race/ethnicity
Non-Hispanic White	90.4 (574)
African American	5.4 (34)
Hispanic	4.3 (27)
Age
65-74	64.1 (407)
≥75	35.9 (228)
Sex
Male	41.3 (262)
Female	58.7 (373)
Education
≤High school	41.9 (266)
>High school	58.1 (369)
Health status
Body mass index
25-29.9 (Overweight)	57.0 (362)
30-34.9 (Moderately obese)	29.9 (190)
≥35 (Severely obese)	13.1 (83)
Physical health not good
None	50.9 (323)
1-7 days	25.2 (160)
≥8 days	23.9 (152)
Number of chronic conditions
0-1	28.0 (178)
2	36.1 (229)
≥3	35.9 (228)
PHQ-9^a
No depression	40.6 (258)
≥Mild depression	59.4 (377)
Health behaviors
Fast food consumption
Never-3 times a month	56.4 (358)
1-2 times a week	29.1 (185)
≥3 times a week	14.5 (92)
Watching television
<2 hr	25.4 (161)
2-4 hr	41.7 (265)
≥4 hr	32.9 (209)
Health care utilization
Number of visit to doctor’s office
0-2	28.2 (179)
3-4	31.8 (202)
≥5	40.0 (254)
Routine check-up
> in the past year	14.0 (89)
In the past year	85.9 (546)

PHQ9 (Patient Health Questionnaire).

Bivariate analyses

A significantly larger proportion of older adults with higher BMI levels, more chronic conditions, and more visits to the doctor’s office reported being recognized as overweight or obese by a health care provider and discussing their healthy diet and physical activity with a health care provider (all p < .01) (Table 2). In addition, being recognized as overweight or obese by their health care provider was associated with the following characteristics: aged 65-74 (p = .008), higher educated (p = .024), feeling physically bad more days (p = .003), more consumption of fast food (p = .038), and television watching (p = .035). The higher educated were less likely to discuss healthy diets with health care provider (p = .044).

Table 2.

Descriptive and Bivariate Results Among Study Participants Who Were Overweight or Obese (n = 635)

	Recognized as overweight/obese		Discussed healthy diets		Discussed physical activity
	No	Yes	No	Yes	No	Yes
Variables	% (n)	% (n)	% (n)	% (n)	% (n)	% (n)
Demographic factors
Race/ethnicity
Non-Hispanic White	89.9 (331)	91.0 (243)	92.4 (290)	88.5 (284)	91.5 (279)	89.4 (295)
African American	5.7 (21)	4.9 (13)	4.1 (13)	6.5 (21)	4.6 (14)	6.1 (20)
Hispanic	4.4 (16)	4.1 (11)	3.5 (11)	4.98 (16)	3.9 (12)	4.6 (15)
Age
65-74	59.8 (220)	70.0 (187)	60.5 (190)	67.6 (217)	61.9 (189)	66.1 (218)
≥75	40.0 (148)	29.9 (80)	39.5 (124)	32.4 (104)	38.0 (116)	33.9 (112)
Sex
Male	42.1 (155)	40.1 (107)	37.6 (118)	44.9 (144)	40.9 (125)	41.5 (137)
Female	57.9 (213)	59.9 (160)	62.4 (196)	55.1 (177)	59.0 (180)	58.5 (193)
Education
≤High school	45.7 (168)	36.7 (98)	37.9 (119)	45.8 (147)	39.7 (121)	43.9 (145)
>High school	54.4 (200)	63.3 (169)	62.1 (195)	54.2 (174)	60.3 (184)	56.1 (185)
Health status
Body mass index
25-29.9 (Overweight)	77.9 (287)	28.1 (75)	66.9 (210)	47.4 (152)	64.9 (198)	49.7 (164)
30-34.9 (Moderately obese)	18.8 (69)	45.3 (121)	26.1 (82)	33.6 (108)	24.9 (76)	34.6 (114)
≥35 (Severely obese)	3.3 (12)	26.6 (71)	7.0 (22)	19.0 (61)	10.2 (31)	15.8 (52)
Physical health not good
None	56.5 (208)	43.1 (115)	54.8 (172)	47.0 (151)	54.1 (165)	47.9 (158)
1-7 days	22.8 (84)	28.5 (76)	23.3 (73)	27.1 (87)	23.6 (72)	26.7 (88)
≥8 days	20.7 (76)	28.5 (76)	21.9 (69)	25.9 (83)	22.3 (68)	25.5 (84)
Number of chronic conditions
0-1	37.2 (137)	15.4 (41)	34.4 (108)	21.8 (70)	36.7 (112)	20.0 (66)
2	37.2 (137)	34.5 (92)	35.4 (111)	36.8 (118)	33.1 (101)	38.8 (128)
≥3	25.5 (94)	50.2 (134)	30.3 (95)	41.4 (133)	30.2 (92)	41.2 (136)
PHQ-9^a
No depression	49.2 (181)	28.8 (77)	40.1 (126)	41.1 (132)	44.6 (136)	36.9 (122)
≥Mild depression	50.8 (187)	71.2 (190)	59.9 (188)	58.9 (189)	55.4 (169)	63.0 (208)
Health behaviors
Fast food consumption
Never-3 times a month	60.6 (223)	50.1 (135)	57.9 (182)	54.8 (176)	57.1 (174)	55.8 (184)
1-2 times a week	25.8 (95)	33.7 (90)	25.5 (80)	32.7 (105)	24.6 (75)	33.3 (110)
≥3 times a week	13.6 (50)	15.7 (42)	16.6 (52)	12.5 (40)	18.4 (56)	10.9 (36)
Watching television
<2 hr	27.2 (100)	22.9 (61)	25.8 (81)	24.9 (80)	28.2 (86)	22.7 (75)
2-4 hr	44.0 (162)	38.6 (103)	44.9 (141)	38.6 (124)	42.6 (130)	40.9 (135)
≥4 hr	28.8 (106)	38.6 (103)	29.3 (92)	36.5 (117)	29.2 (89)	36.4 (120)
Health care utilization
Number of visit to doctor’s office
0-2	33.2 (122)	21.4 (57)	35.7 (112)	20.9 (67)	35.7 (112)	20.9 (67)
3-4	31.3 (115)	32.6 (87)	28.9 (91)	34.6 (111)	28.9 (91)	34.6 (111)
≥5	35.6 (131)	46.1 (123)	35.4 (111)	44.6 (143)	35.4 (111)	44.6 (143)
Routine check-up
> in the past year	14.7 (54)	13.1 (35)	16.6 (52)	11.5 (37)	16.6 (52)	11.5 (37)
In the past year	85.3 (314)	86.9 (232)	83.4 (262)	88.5 (284)	83.4 (262)	88.5 (284)

PHQ9 (Patient Health Questionnaire); Bold is considered significant at p < .05.

Multivariate analyses

The first logistic regression identifies factors associated with being recognized as overweight or obese by a health care provider (Table 3). Those who were more educated (OR = 2.31, p < .001), had higher BMI (moderately or severely obese; OR = 6.80, p < .001; OR = 23.55, p < .001, respectively), had more chronic conditions (2 or 3+) (OR = 1.79, p = .027; OR = 3.32, p < .001, respectively), had at least mild depression (OR = 1.64, p = .025), and consumed fast food 1 to 2 times a week (OR = 1.64, p = .029) were more likely to be recognized as overweight or obese by a health care provider.

Table 3.

Logistic Regression of Being Recognized as Overweight or Obese by Health Care Providers (n = 635)

Predictor	Odds ratio	p value	95% confidence interval
Race/ethnicity
Non-Hispanic White
African American	0.43	.072	0.169	1.080
Hispanic	1.38	.521	0.516	3.686
Education
≤High school
>High school	2.31	<.001	1.501	3.554
Age
65-74
≥75	0.68	.071	0.445	1.034
Body mass index
25-29.9 (Overweight)
30-34.9 (Moderately obese)	6.80	<.001	4.413	10.456
≥35 (Severely obese)	23.55	<.001	11.201	49.514
Physical health not good
None
1-7 days	1.07	.790	0.653	1.752
≥8 days	1.00	.987	0.574	1.727
Number of chronic conditions
0-1
2	1.79	.027	1.067	3.019
≥3	3.32	<.001	1.909	5.772
PHQ-9^a
No depression
≥Mild depression	1.64	.025	1.065	2.533
Fast food consumption
Never-3 times a month
1-2 times a week	1.64	.029	1.052	2.558
≥3 times a week	1.06	.861	0.579	1.925
Watching television
<2 hr
2-4 hr	0.88	.614	0.531	1.453
≥4 hr	1.06	.834	0.620	1.809
Number of visit to doctor’s office
0-2
3-4	1.20	.504	0.706	2.032
≥5	1.23	.428	0.736	2.059
Routine check-up
> in the past year
In the past year	1.30	.380	0.722	2.347

PHQ9 (Patient Health Questionnaire).

The second logistic regression displays correlates contributing to reporting discussions about healthy diets with a health care provider (Table 4). Those who had higher BMI (moderately or severely obese; OR = 1.65, p = .011; OR = 3.53, p < .001, respectively), had more chronic conditions (3+) (OR = 1.73, p = .022), and visited to doctor’s office more often (3-4 times or 5+ times in the past 12 months; OR = 2.01, p = .002; OR = 1.99, p = .002, respectively) were more likely to discuss healthy diets with their health care provider. Conversely, these discussions were less common among those who were female (OR = 0.55, p = .001) and were more educated (OR = 0.66, p = .025).

Table 4.

Logistic Regression of Having Discussed Healthy Diet From Health Care Providers (n = 635).

Predictor	Odds ratio	p value	95% confidence interval
Sex
Male
Female	0.55	.001	0.385	0.792
Race/ethnicity
Non-Hispanic White
African American	1.39	.406	0.637	3.051
Hispanic	1.35	.487	0.581	3.132
Education
≤High school
>High school	0.66	.025	0.460	0.949
Age
65-74
≥75	0.75	.111	0.523	1.069
Body mass index
25-29.9 (Overweight)
30-34.9 (Moderately obese)	1.65	.011	1.121	2.422
≥35 (Severely obese)	3.53	<.001	1.986	6.268
Physical health not good
None
1-7 days	1.27	.273	0.827	1.957
≥8 days	1.03	.900	0.646	1.643
Number of chronic conditions
0-1
2	1.32	.210	0.855	2.037
≥3	1.73	.022	1.082	2.778
PHQ-9^a
No depression
≥Mild depression	0.70	.060	0.476	1.015
Fast food consumption
Never-3 times a month
1-2 times a week	1.36	.113	0.929	2.003
≥3 times a week	0.60	.053	0.361	1.006
Watching television
<2 hr
2-4 hr	0.79	.285	0.519	1.213
≥4 hr	1.02	.933	0.644	1.614
Number of visit to doctor’s office
0-2
3-4	2.01	.002	1.289	3.130
≥5	1.99	.002	1.279	3.087
Routine check-up
> in the past year
In the past year	1.57	.075	0.955	2.595

PHQ9 (Patient Health Questionnaire).

The third logistic regression reveals correlates contributing to reporting discussions about physical activity with a health care provider (Table 5). Those who were moderately obese (OR = 1.59, p = .018), had more chronic conditions (2 or 3+) (OR = 1.81, p = .007; OR = 1.94, p = .005, respectively), visited to doctor’s office more often (3-4 times or 5+ times in the past 12 months; OR = 2.06, p = .001; OR = 1.73, p = .012, respectively), and had routine check-up in the past year (OR = 1.94, p = .009) were more likely to discuss physical activity with their health care provider. Yet the discussion was less common among those who consumed fast food more than 3 times a week (OR = 0.52, p = .010).

Table 5.

Logistic Regression of Having Discussed Physical Activity From Health Care Providers (n = 635)

Predictor	Odds ratio	P value	95% confidence interval
Race/ethnicity
Non-Hispanic White
African American	1.34	.449	0.629	2.855
Hispanic	1.32	.509	0.579	3.012
Age
65-74
≥75	0.79	.185	0.553	1.121
Body mass index
25-29.9 (Overweight)
30-34.9 (Moderately obese)	1.59	.018	1.081	2.331
≥35 (Severely obese)	1.67	.064	0.971	2.860
Physical health not good
None
1-7 days	1.02	.932	0.667	1.555
≥8 days	0.88	.600	0.560	1.398
Number of chronic conditions
0-1
2	1.81	.007	1.179	2.780
≥3	1.94	.005	1.221	3.079
PHQ-9^a
No depression
≥Mild depression	1.10	.610	0.761	1.592
Fast food consumption
Never-3 times a month
1-2 times a week	1.36	.115	0.929	1.982
≥3 times a week	0.52	.010	0.312	0.852
Watching television
<2 hr
2-4 hr	1.14	.540	0.750	1.731
≥4 hr	1.30	.248	0.832	2.035
Number of visit to doctor’s office
0-2
3-4	2.06	.001	1.331	3.188
≥5	1.73	.012	1.128	2.669
Routine check-up
> in the past year
In the past year	1.94	.009	1.184	3.185

PHQ9 (Patient Health Questionnaire).

Discussion

The current study showed that recognizing obesity and providing advice for diet and exercise are not yet a routine part of every clinical encounter: 42%, 51%, and 52% of study participants who were overweight or obese reported being recognizing as overweight or obese, discussing healthy diets, and discussing physical activity with their health care provider, respectively. A previous study documented comparable results: 51%, 38%, and 43% of study participants who were obese reported discussing weight, nutrition, and exercise, respectively with their health care provider (Ely et al., 2006). The current study is unique to demonstrate factors associated with physician-older patient encounters regarding weight status, diets, and physical activity and discuss potential recommendations to improve these encounters.

This examination of doctor-patient encounters with overweight or obese patients reveals that physician’s discussions depended upon patient’s sociodemographic as well as clinical characteristics (e.g., chronic condition profile). As the BMI categories increased in severity, they were more likely to be recognized as overweight or obese, as well as being counseled about healthy diets and physical activity. This suggests health care providers were more likely to recognize weight problems and discuss healthy eating and physical activity when their patients were moderately or severely obese as compared to being just overweight. This represents a potential missed opportunity for health care providers to guide their patients who are overweight to make changes in dietary intake and physical activity (van Genugten, van Empelen, Flink, & Oenema, 2010), given that only about 10% of physician-older patient encounters were spent on discussing physical activity, nutrition, or smoking topics (Ory et al., 2007). The 2008 Physical Activity Guidelines for Americans also support that science-based guidance can help Americans aged 65 and older improve their health through appropriate physical activity (U.S. Department of Health Human Services, 2008). Weight loss or weight management for these patients can prevent them from being obese and developing chronic conditions (Houston, Nicklas, & Zizza, 2009).

The current study also showed that more frequent visits to a doctor’s office were associated with a greater chance to discuss healthy diets and physical activity. We speculate that patients who visited their physician more often were likely to have greater levels of illness and may have been advised to follow behavioral interventions as well as medication regimens to improve their conditions. On the other hand, we also think better access to health care can give both health care providers and patients more opportunities to discuss needed lifestyle changes. Either interpretation is consistent with prior studies that reported higher access to care and higher frequency of visits can give providers with opportunities to discuss behavioral change (Berkel, Carlos Poston, Reeves, & Foreyt, 2005; Lerman, 2005; Levy, Finch, Crowell, Talley, & Jeffery, 2007).

To improve patients’ health conditions, health care providers should acknowledge their patient’s excess body weight as a first step in counseling patients on the importance of normalizing energy balance for weight management (van Genugten et al., 2010). Older patients are especially likely to accept risk communication messages and follow recommendations from authorities whom they perceive as credible and trustworthy (Lemyre, Gibson, Zlepnig, Meyer-Macleod, & Boutette, 2009). However, we found only 42% of patients with excess body weight reported being recognized as overweight or obese by a physician. Without being aware of their weight problems, it is difficult to expect overweight and obese older adults to behave in ways to improve their body composition. There may be an inherent conflict between health care providers and their patients both telling and listening to messages about weight problems. Prior studies have found that health care providers were unwilling to inform patients about their excess body weight (Hall, 2010; Kushner, 2010; O’Neil & Nicklas, 2007), and patients were reluctant to consider themselves as overweight or obese (Johnson, Cooke, Croker, & Wardle, 2008). Although issues about weight are sensitive and hard to accept for many patients, we urge health care providers to focus on the significance of overweight or obesity for overall health and well-being. An emphasis on properly framing the conversation and recommendations about weight-related issues can assist physicians to deliver sensitive medical messages to their patients in an effective manner (Sargeant, Valli, Ferrier, & MacLeod, 2008; Teixeira & Budd, 2010).

Further, only half of overweight and obese participants in our study reported discussing healthy eating and physical activity with their health care providers. Similarly, a previous study found that less than half of obese adults reported being advised to lose weight by their health care professionals (Galuska, Will, Serdula, & Ford, 1999). The results indicate a lack of guideline adherence to USPSTF recommendations about healthy eating (Pignone et al., 2003) or the Surgeon General’s recommendations about physical activity (National Center for Chronic Disease Prevention and Health Promotion, 1999). These findings may also represent physicians’ missing a unique and necessary opportunity to help patients improve body composition by engaging them in effective behavioral interventions to facilitate weight loss especially among older adults who are overweight and obese (Shah et al., 2009).

The “awareness-to-adherence” model suggests health care providers should be aware of a guideline, agree with it, adopt it as a part of care, and adhere to the guideline (Pathman, Konrad, Freed, Freeman, & Koch, 1996). Following the model, health care providers are more likely to suggest behavioral changes, including eating more fruit or vegetables and being more physically active when their patients have excess body weight. However, being aware of such guidelines does not equate to being able to implement the guideline in practice (Linder, Schnipper, Tsurikova, Volk, & Middleton, 2010).

In an effort to assist office practices, providing health care professionals with chart stickers and checklist forms would serve to remind a practitioner about key practice guideline topics for counseling and minimize the physician’s effort necessary to document that the patient received care (Richman & Lancaster, 2000). Given that time constraints are well-known hindrances for health care providers to provide behavioral interventions, older patients who are overweight or obese can be advised to complete a short form regarding their eating habits and physical activity when they are sitting in a physician’s office waiting room. This information may serve as a reminder of discussing behavioral changes to both patients and physicians. For geriatric patients, we also recommend that supplemental educational materials like patient leaflets or interactive kiosks designed to reflect behavior change principles (Ory, Lee Smith, Mier, & Wernicke, 2010) be developed that are consumer-friendly and culturally- and age-appropriate.

The current study also found that older adults with higher education and who were overweight or obese tended to be recognized as overweight or obese and to discuss healthy diets with their health care providers. Although the association of socioeconomic status with obesity has been documented (Bove & Olson, 2006), few studies reported the relationship between educational attainment and recognition of overweight or obesity as well as discussion about healthy eating. One probable explanation is that those who are higher educated are likely to have more financial resources to better access health care systems, which can increase their chances of getting recognized as overweight or obese. Higher educational attainment can increase the awareness of healthy lifestyles and the ability to use health-related information (Sobal, 1991), which may lead to more discussion about eating habits with their health care providers. Given patient’s educational level is important to address weight concerns in physician and patient communication, we believe a patient-centered approach such as the ACE-ME (i.e., assessment, collaboration, education, monitoring, and evaluation) model can improve health outcomes of the patient (Bergman-Evans, 2006; Gould & Mitty, 2010).

One interesting finding from the current study is the positive association between the patients’ depression and being recognized as overweight or obese by a health care provider. Despite the strong association between depression and overweight or obesity among older adults (Vogelzangs et al., 2008), few studies have documented how older adults with depressive symptomology were more likely to be recognized as overweight or obese. Given the strong association between depression and overweight or obesity, it seems natural for older adults with depression to be more recognized as overweight or obese. A possible explanation may be that older adults with depression tend to report poor eating habits (Kuczmarski et al., 2010) and less physical activity (Lindwall, Larsman, & Hagger, 2011), which may in turn receive physician’s attention about their patients’ weight status. Although proactive actions taken by health care providers seem important for their older patients who were overweight or obese and reported depressive symptomology, the current study found no evidence that health care providers discussed healthy diets and physical activities with those patients. Future studies should identify barriers related to health care providers not discussing healthy eating and physical activity lifestyles with their patients.

Our analysis had several limitations that can potentially affect our study results. First, the current study is based on cross-sectional dataset, which limit the ability to untangle cause-and-effect relationships in physician-older adult interactions regarding weight, healthy eating, and physical activity. Second, all items, including weight and height, in the survey were self-reported. We also acknowledge that health care providers may have actually discussed behavioral interventions with their patients, but some patients may have not recalled the discussion because of hearing or memory deterioration, or may be in denial about their weight problems. However, our dataset did not include variables to facilitate assessment of participants’ cognitive capacity. While we recognize that age may be positively associated with cognitive impairment, this relationship is not inevitable or present in a linear fashion. Nevertheless, a recent study reported significant agreement between self-reported BMI and measured BMI values among older adults (i.e., 79% of men and 77% of women; Hasnain-Wynia, Taylor-Clark, & Anise, 2011). Next, the outcome variables of the current study are based a single survey questions, which may prevent us from understanding in-depth characteristics of the physician-older adult interactions regarding the initiator of the discussion, length of the discussion, and reason for the discussion. Future qualitative or quantitative study may answer these questions.

Despite these limitations, our study may have important clinical implications. The current study showed a positive aspect of the practitioners’ role in recognizing weight problems and engaging in behavioral interventions when their older patients had multiple chronic conditions. Conversely, our results suggest that the frequency of being recognized as overweight or obese and discussing healthy diets and physical activity with health care providers is less than ideal during physician-patient encounters including older adults with excess body weight. Given obesity is considered an underlying cause of many chronic conditions, proactive actions may improve body composition and multiple chronic conditions among older adults with weight problems, and thus be further encouraged.

Footnotes

Authors’ Note

This project was conducted by investigators who are part of the Central Texas: Cancer, Awareness, Research, Education & Support (CTxCARES). CTxCARES is supported by the Centers for Disease Control and Prevention and the National Cancer Institute [cooperative agreement number 1U48DP001924]. The authors recognize faculty support from the Center for Community Health Development, which is a member of the Prevention Research Centers Program, supported by the Centers for Disease Control and Prevention [cooperative agreement number 5U48 DP000045]. The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention or the National Cancer Institute.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

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