Obesity Management in Primary Care: Assessment of Readiness to Change...
Background: Most adults in primary care are overweight or obese; two thirds of patients with weight problems have other obesity-related conditions. The study objective was to explore the feasibility of a primary care obesity intervention based on the transtheoretical model (TM) of behavior change and principles of chronic disease (CD) care.
Methods: A prospective study of the initial version of the TM-CD intervention with obese family practice patients (n = 284) yielded cross-sectional data on baseline stage of change for six target behaviors: dietary fat, portion control, vegetable intake, fruit intake, usual physical activity, and planned exercise. The sample consisted of obese patients scheduled for an office visit during times when recruitment and informed consent did not conflict with acute care.
Results: Obese patients volunteering for a TM-CD program are in different stages of change for six target behaviors. Preparation was the most frequently reported stage for increased exercise (49%) or activity (34%), decreased dietary fat consumption (44%), and increased portion control (51%). Patients in a particular stage for one behavior were distributed across all five stages for another behavior. Stage of change for five target behaviors was associated with body mass index or waist girth (P < .05) in a manner consistent with stage-of-change theory.
Conclusions: Using the transtheoretical model of behavior change will allow physicians to recognize when obese patients are receptive to specific behavioral interventions.

The National Institutes of Health (NIH) recently announced what many primary care physicians have known for years - that most adults in this country (55%) are overweight (body mass index between 25.0 and 29.9) or obese (body mass index of 30.0 or more). Two thirds of patients with weight problems are also likely to have hypertension, hyperlipidemia, diabetes, coronary artery disease, or another obesity-related comorbid condition. Because most obese patients are initially seen in primary care, obese patients are encountered during a substantial percentage of office visits. Thus, obesity and its sequelae are serious challenges to primary care and have implications for both chronic disease and practice management.

Although obesity poses a serious health threat, and obesity-related illnesses strain health care resources, few obese primary care patients receive effective treatment. Primary care physicians might offer a brief educational encounter consisting of a lecture on the risks of obesity and might advise obese patients to eat less and exercise more. Time constraints of primary care, however, often prevent discussion of how to implement the eat-less, exercise-more prescription and can limit the physician's opportunity to consider the patient's emotional status or to apply principles of behavior change to patients' eating and exercise habits. Additional obstacles include the reluctance of insurance companies to reimburse physicians for obesity counseling and management, and the cost and time required to provide adequate follow-up care for obese patients. In light of the realities of primary care, it is understandable that physicians undertreat obesity.

Some primary care physicians refer obese patients to specialized obesity treatment programs. These programs, which usually include short-term or fixed-duration therapy groups at a clinical center, teach a variety of dieting and lifestyle skills (physical activity, stress management) under the direction of weight-loss counselors. Although several of these specialized interventions have been shown to be effective, particularly those involving cognitive-behavioral counseling and physical activity, they also have serious limitations. Because these programs are usually offered at a centralized location and require the patient to travel to the weight-loss center, many obese patients never find their way to a treatment group. For those who do, the autonomy of the treatment program discourages communication between weight-loss counselors and primary care physicians. Furthermore, even the most effective fixed-length obesity treatment program fails to make an impact on the long-term health of 75% of patients, because the initial weight loss is followed by relapse and weight regain.

The NIH guideline recommends treatment for obesity. The guideline, however, does not describe how treatment can be feasibly implemented in primary care practice. In light of the problems described above, we reasoned that for an obesity treatment to be truly effective, it would have to be readily available to all patients, integrated into the patient's other medical treatment, cost-effective, and efficacious in the long-term.

One strategy for managing obesity in primary care that meets these criteria involves viewing obesity as a chronic disease. Because the origin and course of obesity are similar to a variety of chronic conditions, it seems more reasonable to try to prevent or manage obesity rather than to cure it with a single session of advice or a short-term program. Managing obesity as a chronic condition would involve the same components of primary care used successfully with other chronic conditions: periodic reassessments, life-span access to counseling and other treatments, and continuity of care by health care personnel who are aware of the patient's biopsychosocial history.

Obese patients differ in their commitment to weight loss as well as their ability to make the complex behavioral and cognitive changes required for life-long weight control. Nonetheless, many formal obesity treatments rely on uniform dietary, exercise, or cognitive-behavioral protocols. We hypothesized that a treatment would be more effective if it could be tailored to the patient's readiness and ability to change target behaviors. This hypothesis is based on the transtheoretical model of behavior change. The transtheoretical model assumes that patient readiness to make changes on relevant behaviors can be assessed or assigned to a stage, and that treatment efficacy can be enhanced by applying the cognitive and behavioral change processes that are best suited to the patient's stage.

After recognizing that obesity is a complex, chronic condition and that obese patients are highly diverse, we hypothesized that obese patients would benefit most from treatment that combines the principles of chronic disease management in primary care with the transtheoretical model of behavior change. The general purpose of the study summarized in this report was to investigate the feasibility of a primary care intervention for obesity based on a combined transtheoretical model- chronic disease (TM-CD) paradigm. More specifically, we attempted to measure stage of change for six target behaviors in a sample of obese primary care patients, because the model dictated that this step is first in tailoring treatments. One objective of the study was to explore the heterogeneity of stages for the six target behaviors. A second objective was to examine the relations between anthropometric indices and the stages of change.