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Keywords:

  • 5As framework;
  • obesity management;
  • physician–patient communication;
  • primary care

Summary

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conflict of Interest Statement
  8. Acknowledgements
  9. References
  10. Supporting Information

What is already known about this subject

  • Obesity counselling in primary care is positively associated with self-reported behaviour change in patients with obesity.
  • Obesity counselling is rare, and when it does occur, it is often of low quality because of poor training and/or competency of providers' obesity management, lack of time and economical disincentives, and negative attitude towards obesity and obesity management.
  • 5As frameworks are routinely used for behaviour-change counselling and addiction management (e.g. smoking cessation), but few studies have examined its efficacy for weight management.

What this study adds

  • This study presents pilot data from the implementation and evaluation of an obesity management tool (5As of Obesity Management developed by the Canadian Obesity Network) in a primary care setting.
  • Results show that the tool facilitates weight management in primary care by promoting physician–patient communications, medical assessments for obesity and plans for follow-up care.

Obesity remains poorly managed in primary care. The 5As of Obesity Management is a theory-driven, evidence-based minimal intervention designed to facilitate obesity counselling and management by primary care practitioners. This project tested the impact of implementing this tool in primary care clinics. Electronic self-administered surveys were completed by pre-screened obese subjects at the end of their appointments in four primary care clinics (over 25 healthcare providers [HCPs]). These measurements were performed before (baseline, n = 51) and 1 month after implementing the 5As of Obesity Management (post-intervention, n = 51). Intervention consisted of one online training session (90 min) and distribution of the 5As toolkit to HCPs of participating clinics. Subjects completing the survey before and after the intervention were comparable in terms of age, sex, body mass index, comorbidities, satisfaction and self-reported health status (P > 0.2). Implementing the 5As of Obesity Management resulted in a twofold increase in the initiation of obesity management (19 vs. 39%, P = 0.03), and caused a statistically significant increase in the perceived follow-up/coordination efforts (self-reported Patient Assessment of Chronic Illness Care components, 45 ± 22 vs. 67 ± 12 points, P = 0.002), as well as two components of the 5As framework: Assess (50 ± 29 vs. 66 ± 15 points, P = 0.03) and Assist (54 ± 26 vs. 72 ± 13 points, P = 0.01). Our results suggest that using the 5As of Obesity Management facilitates weight management in primary care by promoting physician–patient communications, medical assessments for obesity and plans for follow-up care.


Introduction

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conflict of Interest Statement
  8. Acknowledgements
  9. References
  10. Supporting Information

Rates of obesity have reached epidemic proportions in Canada [1, 2]. With 75% of total healthcare spending consumed by the management of chronic diseases, action is urgently needed to address the root causes of many chronic diseases [3]. Long-term, multicomponent interventions performed by primary healthcare providers (HCPs) are proven to offer substantial benefits for obesity management and prevention [4].

Obesity counselling in primary care is positively associated with self-reported behaviour change in patients with obesity [5]. However, HCPs often fail to promote this kind of interaction, and when they do, it is often of low quality [5-7]. Common reasons for this include: poor training and/or competency of the HCPs in obesity management [8], lack of time and economical disincentives [9], and negative attitude towards obesity and obesity management [10].

The 5As of Obesity Management, developed by the Canadian Obesity Network, provides a theory-driven, evidence-based, minimal intervention that can help physicians to start the conversation about weight and health with their patients, and provide effective support for obesity management, behaviour change and improved health. The modified 5As framework encourages HCPs to: Ask permission to discuss a patient's weight and determine their readiness to change; Assess risk, obesity stage and class and current unhealthy behaviours, as well as other aetiological factors such as mental, metabolic, mechanical and economical barriers; Advise on obesity risks and therapeutic alternatives; Agree on collaboratively set goals; and Assist in accessing the appropriate providers, education resources and arranging follow-up.

A similar 5As framework is extensively utilized in addiction management. In smoking cessation counselling for instance, a 5As counselling approach is linked to higher motivation and more quit attempts among smokers [11]. Preliminary research suggests that this technique could also be useful for obesity counselling. Some physicians are already using certain elements of these techniques with their overweight and obese patients [12]. However, the individual application of this framework is not completely standardized and is believed to be subutilized by HCPs [13].

The main objective of this project was to evaluate the impact of an obesity management tool in primary care settings and to determine its impact on weight and health. Based on preliminary pilot testing of this tool, we hypothesize that implementation of the 5As of Obesity Management tool in primary care will: (i) increase the number and quality of interactions regarding weight management between HCPs and patients with overweight and obesity and (ii) improve patient motivation and intentions to better manage their weight.

Methods

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conflict of Interest Statement
  8. Acknowledgements
  9. References
  10. Supporting Information

Subjects and design overview

All stages of this project were performed in collaboration with the South Calgary Primary Care Network (SCPCN), which provides primary care services to over 217 268 patients a year through a network of 203 HCPs in 33 different primary care practices, located in the south side of Calgary, Alberta, Canada. All procedures in this study were approved by the Canadian Shield Ethics Review Board.

This study used a non-controlled quasi-experimental (before and after) design. Two observation periods (baseline and 1 month after intervention) were predetermined. Front desk clerks of four participating clinics were trained to identify and approach every patient with a chart-recorded body mass index (BMI) of 30 kg m−2 or greater. Clerks were instructed to enrol every consecutive patient who met the inclusion criteria, and continue the systematic screening process until sample size was achieved on each observation period. Exclusion criteria included: insufficient English communication skills and presenting with acute illness requiring priority medical management (such as pain, fever, infectious disease, upper respiratory tract infection, shortness of breath, palpitations or dizziness) [13].

Both patients and clerks were aware of the academic nature of the surveys, but were blinded to other details such as the design, intervention type and outcomes of interest or observation periods. Similarly, HCPs were blinded to the timing and objectives of the evaluations performed with the patients as they left the clinic.

Variables of interest and data collection

Patients accepting to participate were approached by clerks at the end of their appointments and asked to complete an internet-based self-administered survey (Appendix S1) using an iPad (Apple Inc., Palo Alto, CA, USA) connected to the Internet trough a secure wireless network. Patients were also given the option to receive an e-mail invitation to complete the survey online at their convenience during the following 24 h. Survey information was recorded directly using an online data acquisition instrument designed using a RedCap® platform (Research Electronic Data Capture, http://www.project-redcap.org)

Questions in the survey were designed to collect patient characteristics and the patient's perception of their recent interactions with their HCP, and factors that could potentially influence quantity and quality of interactions. Health literacy of participant was assessed using one screening question about ability to read and complete health-related documents [14]. The patient's stage of change was assessed by asking participants whether, in the past month, they have been actively trying to lose weight (or not to gain weight). Application of the 5As approach for obesity counselling and management was evaluated using an adapted version of the Patient Assessment of Chronic Illness Care (PACIC) instrument [13-18]. The average time for completing this survey was 15 min.

Intervention

After the collection of baseline surveys, HCPs working in the participating clinics (n = 25) participated in a 90-min standardized training programme about the 5As of Obesity Management, and were provided with the printed and electronic material designed to facilitate and implement the 5As tool in their clinical practice. The structure and content of this training has recently been adapted as a certified online educative module currently available through the International Association for the Study of Obesity (http://www.iaso.org).

Statistical analyses and sample size calculation

A ‘5As management score’ was calculated and reported, and each item in the PACIC instrument was scored from 1 to 5, as previously described [13]. PACIC summary scores were obtained by calculating the average in items 1–20 of Appendix S1. Scores of individual domain components were calculated separately (patient activation [items 1–3]; delivery system design/decision support [items 4–6]; goal setting [items 7–11]; problem-solving/contextual counselling [items 12–15]; and follow-up/coordination [items 16–20]). Use of the 5As components were scored by calculating the corresponding domain averages present in the PACIC: Ask/Assess (items: 3, 11, 15, 20, 21, 22); Advise (items: 4, 6, 19, 24); Agree (items: 1, 2, 7, 8, 25); Assist (items: 9, 10, 12, 13, 14, 26); and Arrange (items: 16, 17, 18, 23, 27). The primary outcome of the study was the change in the multiple components of the PACIC score. Significance of the effect of the intervention in these parameters was tested using Student's t-test or χ2 test according to the characteristics of the variables. A P value < 0.05 was considered statistically significant.

A sample size of 51 subjects on each predetermined observation period was predefined in order to achieve a 90% power to detect a minimum of 15 points (50–65 points in any of the PACIC components with standard deviation of 20 points) after 10% correction for incomplete data (alpha 0.05).

Results

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conflict of Interest Statement
  8. Acknowledgements
  9. References
  10. Supporting Information

Between August and October of 2012, 145 patients attending one of four SCPCN clinics were screened in two different observation periods (baseline: n = 76 and post-intervention: n = 69). Sex, age, BMI and reasons for exclusion were similar among subjects who were screened but not included in either observation periods (data not shown). General characteristics of participating subjects and the main results of the study are presented in Table 1. No differences in anthropometric and demographic parameters were observed between subjects included in the different observation periods. Similarly, self-reported literacy, health status, satisfaction, number of previous medical visits, primary reasons for visiting the clinic, prevalence of common chronic comorbidities and perceived intention to lose weight were comparable between observation periods.

Table 1. General characteristics of participants and results
 BaselinePost-trainingP value
n(SD)/%n(SD)/%
  1. *Identifies parameter measured with a self-reported visual analogue scale between 0 and 100. Lower values represent the lowest for each parameter.

  2. BMI, body mass index; HCP, healthcare provider; SD, standard deviation; TOPS, TOPS: TOPS Club, Inc. is a nonprofit, weight-loss support and wellness education organization. (http://www.tops.org)

  3. P values less than 0.05 are presented in bold fonts.

Subjects screened76 69  
Subjects included5167.15173.90.4
Age (years)47.21351130.1
Sex (male) 45 430.8
Weight (kg)90.8(16)91(20)0.9
Height (cm)169(9)170(10)0.6
BMI (kg m−2)31.5(5)31.2(6)0.7
Clinic     
#1 18 190.7
#2 12 14 
#3 23 29 
#4 47 37 
Patient's literacy*11.3158.8140.4
Self-reported health*62(23)69(18)0.1
Seen by the primary HCP (%) 76 800.8
Patient's satisfaction*85(14)87(11)0.5
Number of visits to HCP in the previous year    0.9
0 2 4 
1 10 12 
2 22 22 
3 16 12 
4 16 18 
>4 34 32 
Primary reason for visit    0.3
Annual check up 6 16 
Consulting for new symptoms or acute disease 12 26 
First time appointment 2 2 
Follow-up on previous health condition 32 37 
Other reason 28 18 
Prescription refill 22 12 
Comorbidities     
Diabetes mellitus 8 170.1
Dyslipidemia 25 230.8
Hypertension 33 350.8
Obesity 31 270.6
Depression 16 190.6
Fatty liver 6 20.3
Procedures performed during the encounter     
Blood pressure check 27 350.4
Weight check 18 180.9
Waist check 10 80.4
Intention to lose weight     
Recent attempts to lose weight (yes) 67 620.5
Conversation initiation     
Did HCP discuss weight management (yes) 19 390.03
Time use to discuss weight management*47.3(28.5)48.8(29)0.9
Did HCP mention the target weight loss (yes)0024.
Target weight loss set by the patient (lbs)50(28)56(43)0.7
Did HCP discuss physical activity (yes) 18 270.4
Time used to discuss barriers to lose weight*54(36)55(34)0.4
Referrals     
Weight management clinic 10 150.3
Weigh Watchers 0 0.
TOPS 0 0.
Other commercial programme 0 0.
Dietitian 2 60.3
Physical or exercise therapist 0 2.
Psychologist 2 60.3
Bariatric surgeon 0 0.
Other 6 40.3

At baseline, 19% of patients with obesity reported that their HCP initiated a conversation about their weight. Implementing the 5As tool and training, the HCP did not affect the frequency of some standard practices such as measuring blood pressure, body weight or waist circumference. However, it did cause a significant increase (19–39%, P = 0.03) in the number of subjects reporting a dialogue about weight management. Training HCPs in the use of the 5As tool also improved the follow-up/and coordination activities during the interaction with the HCP (Fig. 1), and increased the use of all the obesity management 5As components during interaction with HCPs. This change in HCPs behaviours was statistically significant for both Assess and the Assist components (Fig. 2).

figure

Figure 1. Perception of the Patient Assessment of Chronic Illness Care (PACIC) components self-reported by patients immediately after interacting with their healthcare provider (HCP) (Data obtained from subjects when conversation about weight management was conducted during the interaction). *Represents statistical significance when compared with baseline measurements.

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figure

Figure 2. Use of each one of the 5As components self-reported by patients immediately after interacting with their healthcare provider (HCP) (Data obtained from subjects when conversation about weight management was conducted during the interaction). *Represents statistical significance when compared with baseline measurements.

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Discussion

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conflict of Interest Statement
  8. Acknowledgements
  9. References
  10. Supporting Information

Our results suggest that the implementation of the 5As of Obesity Management in a primary care setting can be done in a relatively short period of time and is generally well accepted by HCPs. Results from this study show that implementing this tool was associated with a twofold increase in the number of interactions, in which HCPs initiated a conversation about weight management with obese patients attending to primary care clinics for other reasons.

Consistent with previous reports, our baseline data suggest that a large majority (∼80%) of HCPs do not initiate a conversation about weight management with their patients [8]. Previously reported reasons for avoiding conversations about weight include poor training and/or competency of the HCPs for obesity management [8], lack of time and economical disincentives [9], and a negative attitude towards obesity and obesity management [10]. After 90 min of training with the 5As toolkit, HCPs were more likely to initiate a conversation (Ask) with their patient about weight management.

As with other 5As strategies, our 5As framework uses ‘Ask’ as the first ‘A’. However, unlike the 5As of Smoking Cessation, which directly asks the patient about smoking status, the Ask is used to request the patient's permission to discuss weight and determine their readiness to change. Beginning with ‘Ask’ emphasizes patient-centredness, which increases the quality of the patient–physician interaction. Indeed, Jay and colleagues [13] have previously suggested that that patient-centredness is one of the key measures of the quality of the patient–physician interaction, and that high-quality interactions improve intermediary patient outcomes. Patient-centredness is also positively associated with intentions to eat better (odds ratio [OR] 2.96, 95% confidence interval [CI] 1.03–8.47) and exercise (OR 26.07, 95% CI 3.70–83.93) [13]. It is essential that the Ask is performed in a bias-free, sensitive and non-judgemental manner. The 5As of Obesity Management offers HCPs a method to ask the patient about weight, and a framework to simplify and segment the complex and often difficult discussion about weight in a standardized way.

An important modification of the 5As of Obesity Management compared with the 5As of Smoking Cessation consists of performing the assessment before providing any advice. This modification is a result of feedback from opinion leaders and patients who indicated that they prefer to give and receive advice only upon completion of a thorough assessment. Given the heterogeneity of obesity both in terms of its aetiology and impact on health, as assessment of these factors prior to giving any advice is therefore deemed a better approach for obesity counselling.

Implementation of the 5As was associated with increased assessments (Assess) and follow-up (Assist) components of the interaction with the patient 1 month after training. Previous studies have correlated Assist and Arrange to dietary improvement, and Advise has been associated with increases in motivation and confidence to change dietary fat intake and confidence to lose weight [13]. Increasing motivation is a key aspect of obesity management as it encourages additional interventions from HCPs. However, the 5As may not be the sole driver for increased assessments, follow-up and, subsequently, patient motivation. Future studies should attempt to maintain this result over time and within a large sample size, and differentiate between physician-initiated and patient-initiated assessments.

Assessing and treating obesity can be complex and resource-intensive, requiring ongoing multidisciplinary intervention and monitoring. A recent study demonstrated that patients with higher levels of motivation and intentions to change behaviours and lose weight reported receiving more 5As counselling techniques from their HCPs than those with lower levels of motivation [13]. Each additional counselling practice was associated with increased weight loss motivation (OR 1.31, 95% CI 1.11–1.55), intentions to eat better (OR 1.23, 95% CI 1.06–1.44) and intentions to exercise regularly (OR 1.14, 95% CI 1.00–1.31). Thus, in addition to initiating a dialogue between the physician and the patient about the latter's weight, implementing the 5As of Obesity Management may have some utility favouring health-related behaviour changes as a result of increased motivation and intention to change.

Results from baseline evaluations also showed that, despite interdisciplinary support within the primary care network, a small number of subjects with increased BMI are fully assessed for obesity management. This is consistent with the findings from Alexander et al. [12], showing that although physicians commonly used at least one of the 5As (83%), they often limit their encounters to Ask and Advise but rarely practice Assess, Assist or Arrange [12]. Full implementation of the 5As may therefore be necessary to improve self-reported obesity outcomes. This finding may also result from the relatively low mean BMI of the participants. HCPs may not be recognizing risks of individuals with BMI less than 30 kg m−2. Baseline assessment and advice may increase if BMI is greater than 35 kg m−2.

Limitations of this study include the ones inherent to the quasi-experimental design (such as lack of randomization and blinding), small sample size and the short period of time between intervention and follow-up. In addition, the results of the study may not be applicable to individuals with more severe obesity. Cluster randomized clinical trials are currently in progress and will provide further insight into the long-term impact of the 5As of Obesity Management in weight management in primary care.

In summary, our findings suggest that implementing the 5As of Obesity Management tool in primary practice facilitates weight management in primary care by promoting: physician–patient communications, medical assessments for obesity and plans for follow-up care.

Conflict of Interest Statement

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conflict of Interest Statement
  8. Acknowledgements
  9. References
  10. Supporting Information

The 5As of Obesity Management toolkit is available from the Canadian Obesity Network (http://www.obesitynetwork.ca), a non-profit organization. The authors of this manuscript did not receive any revenues or royalties from the distribution of the 5As of Obesity Management.

Acknowledgements

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conflict of Interest Statement
  8. Acknowledgements
  9. References
  10. Supporting Information

This project was supported by a research grant from the Public Health Agency of (PHAC). CRC is a Clinical Research fellow supported by Alberta Innovates Health Solutions and the Canadian Institute for Health Research. CRC, EB, TB, MV and AMS conceived the study. CRC, TB and RO carried out the study. CRC analysed and interpreted the data. CRC, TB and AMS were involved in writing the paper. All authors had final approval of the submitted and published versions.

References

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conflict of Interest Statement
  8. Acknowledgements
  9. References
  10. Supporting Information

Supporting Information

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conflict of Interest Statement
  8. Acknowledgements
  9. References
  10. Supporting Information
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cob12038-sup-0001-si.pdf145K

Appendix S1. Screening and data collection instrument.

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