T Rutledge, Psychology Service 116B, VA San Diego Healthcare System, Medical Center, 3350 La Jolla Village Drive, San Diego, CA 92161, USA. E-mail: firstname.lastname@example.org
Primary care providers (PCPs) provide the majority of weight management care in clinical settings; however, they often lack the time or resources to apply strategies recommended in treatment guidelines. This review surveyed randomized clinical trials and prospective weight management studies from 1990 to present to identify evidence-based behavioural strategies for weight management applicable to the PCP treatment environment. Data supported, time-limited weight management strategies included self-monitoring, portion control, sleep hygiene, restaurant eating and television viewing. The current review suggests that a number of behavioural strategies are available to enhance the effectiveness of PCPs weight management interventions. Increasing PCP awareness of these evidence-based strategies may increase their attention to overweight and obesity concerns in clinical encounters and encourage more collaborative efforts with patients towards weight management goals.
Primary care providers (PCPs) are uniquely positioned to address weight concerns. With overweight and obesity rates now approaching 68% and 33.8%, respectively, among US adults (1), an increasing percentage of patients presenting in primary care settings face excess adiposity as a barrier to health and quality of life goals. Physician advice is among the strongest predictors of weight management efforts by patients (2,3). For example, the Behavioral Risk Factor Surveillance System study found a nearly threefold increase in-patients' attempts to address their weight (OR = 2.79, 95% CI = 2.53–3.08) (4) following physician advice. Unfortunately, numerous studies show that weight concerns are under-identified and inconsistently addressed by medical providers (2).
Barriers to greater PCP involvement in weight management are well-known (5,6). They include both the pragmatic (lack of time and reimbursement) and the professional (lack of training with behavioural interventions). Guidelines for nonsurgical weight management are available (7–10), yet are often drawn from interventions with considerably more resources and intensity of patient contact than is available to PCPs, consequently translating poorly into practice (11,12). Efforts to transform these multidisciplinary weight management approaches into practical strategies useful to PCPs in the context of time-limited patient encounters appear to be lacking. Identifying evidence-based lifestyle strategies for weight management suitable for PCPs is the focus of this paper.
Changing the frame of reference on weight management
In 1976, charitable organizations received an unexpected boon. Using a technique called ‘legitimizing paltry contributions’, researchers (13) demonstrated that charitable donations could be increased when accompanied by a sign reading ‘every penny helps’ compared with more common slogans such as ‘please give generously’ and ‘every dollar helps’. It turns out that many people wish to donate but fear that their contributions will be seen as cheap or insignificant. Rather than donate and feel inadequate about their offering, they do not give at all. However, change their perspective to see value in even small charitable contributions, and donations increase.
We believe a similar shift in perspective may help in the weight management domain. In a culture of before and after magazine transformations and television shows rewarding extreme weight changes, expectations for radical exercise efforts and rapid weight loss are widespread. Unfortunately, these lofty expectations create disappointment with even objectively impressive body fat reductions (14) and are among the strongest predictors of attrition from dieting efforts (15). As a result, helping overweight and obese patients adjust their perspective to value smaller-scale, less-complex (16) strategies may improve both their initial motivation to engage in weight loss efforts and adherence over time. This approach also holds the advantage of fitting into the types of brief interventions PCPs can implement and follow.
The forthcoming sections describe behavioural weight management strategies that depart from more complex multidisciplinary interventions and instead emphasize PCP applicability and cumulative effects over time. The metabolic effects of these strategies may appear modest on a per day basis. However, few gain or lose appreciable weight in units of days. Previous prospective research indicates that adults in the USA gain a mere 0.4 to 1.8 pounds per year on average (17), figures that represent trivial energy overconsumption on a per day basis. However, the same research shows that these gains are rarely lost. Studies of activity patterns, similarly themed, suggest that obese adults average just 21 min per day less of moderate physical activity than their normal weight peers (18). Viewed in light of such numbers, halting or reversing fat gain does not require Herculean labors in most patients, but rather the development of modest but enduring changes in eating and activity habits. The following sections describe five distinct, evidence-based behavioural habits shown to favorably impact weight and metabolic processes (see Fig. 1).
Accurately assessing caloric intake is difficult even for health professionals; for example, a centre for the Science in the Public Interest study demonstrated that dietitians underestimated the caloric contents of various restaurant foods by an average of 37% (19). Overweight and obese individuals may exhibit particularly poor self-monitoring skills, with one study showing that the estimates of caloric intake and physical activity by ‘diet resistant’ obese patients were under- and overestimated, respectively, by roughly 50% (20). Further, the degree of caloric underestimation appears to rise along with meal size; because overweight and obese individuals are likely to consume larger meals, they are most vulnerable to the effects of underestimating caloric intake (21). Self-monitoring tools for diet and activity, however, can help to overcome these barriers by increasing awareness and accountability, and providing the PCP with a means of understanding discrepancies between self-report habits and weight loss progress.
When self-monitoring methods are utilized, they appear to substantially improve weight management efforts. Among 1685 participants enrolled in a 20-week Dietary Intervention to Stop Hypertension (DASH) programme, food diary regularity was among the strongest predictors of weight changes; keeping a daily food diary was associated with an approximate 20-pound total weight loss vs. less than 10 pounds lost by those who did not keep regular food diaries (22). Post-bariatric surgery patients, tracked over a mean 28.1 months, showed roughly half the risk of weight regain if they engaged in self-monitoring (OR = 0.54, 95% CI 0.30–0.98, P = 0.01) (23). Similarly, in a randomized intervention, daily self-monitoring of weight over the course of eighteen months was associated with a weight regain rate of 26.2% vs. 58.3% among those who did not weigh-in regularly (24). In fairness, the latter studies included dieticians and other non-PCP providers in gauging self-monitoring benefits; however, even in PCP-specific interventions, the inclusion of self-monitoring appears to enhance weight loss outcomes (25).
Another benefit of self-monitoring techniques is that they enable improved consistency of weight management behaviours. Activity and eating patterns, for example, are not only difficult to accurately measure without self-monitoring tools, but are also influenced by weekly and seasonal variations that can contribute substantially to weight gain. For example, a study of seasonal activity levels among a sample of postmenopausal women showed marked differences in daily walking steps across different months (averages of 7616, 6293, 5304 and 5850 in summer, fall, winter and spring months, respectively) (26). These and other documented (27,28) seasonal differences translate into a mile or more per day less walking in the winter and spring compared with summer. In light of research suggesting that winter is the period most prone to weight gain (17), it is possible that subtle and preventable seasonal variations in diet and activity account for much of the gradual weight gain Americans experience over time.
Primary care providers may feel that examining self-monitoring records is not their area of expertise, and it is true that (particularly in the case of food journals) the assistance of a dietician can usually improve the quality of the information gained and the specificity of the recommendations made to patients. Dieticians may also see patients more frequently regarding self-monitoring records, which facilitate the consistency and effectiveness of these strategies. However, given PCPs' closer relationships with patients, and their greater familiarity with the patients' broader medical and social circumstances, they also have important advantages. These advantages include, for example, having greater influence compared with other health care providers to encourage patients' initial use of self-monitoring approaches, the ability to track changes and consistency over longer periods of time, and overcome barriers. Tables 1 and 2 provide a list of specific methods and resources for implementing self-monitoring and the other weight management behaviours discussed, keeping in mind that some patients (e.g. low-income) may have limited access to some resources.
Table 1. Strategies for achieving changes in weight management behaviours
Portion control & restaurants
Use a pedometer or activity journal and aim for increases of 5–10% per month Aim for a walking goal of 8000–10 000 steps or 4–5 miles per day Record activity and food intake as soon as possible Read food labels Plan meal choices before going out Add 20% to any listed calorie content for restaurant meals Use a food journal regularly Weigh weekly to track progress Join a fitness or social website and begin a journal
Use smaller flatware Use meal replacements (e.g. slim-fast) and portion controlled entrees (e.g. lean cuisine) Order the smallest size drink and food items Take home leftovers (wrap up half the meal before eating) Keep food out of sight when not eating Sit away from the sights and smells of the kitchen Remove appetizer and dessert cards
Go to sleep and get up at consistent times Keep the bedroom dark and try to get sunlight in the morning Associate the bedroom with sleep and sex only Remove televisions and other electronics from the bedroom Develop a pre-sleep routine at night Avoid stimulating foods/drinks, exercise, and activating television programmes and video games before bedtime Nighttime food cravings are often a sign of fatigue, a signal to sleep instead of eat
Separate eating from TV watching Remove televisions from bedrooms and eating areas Self-monitor television time in the same way as physical activity and food Limit television use to certain hours Identify activity alternatives to television or exercise while watching TV Use a digital video recorder to record shows and skip advertisements to reduce TV time
Chew more. Put forks/spoons down between bites Use a timer to practice slower eating Eat more frequently. Hunger increases eating speed Use chopsticks rather than a fork Reduce the consumption of processed food, which is made to be easier to chew and faster to eat
Table 2. Resources for weight management strategies
1. Free online food and activity journals (e.g. fitday.com, dailyplate.com and sparkpeople.com) offer flexible, user-friendly options for self-monitoring. 2. iphone applications such as Loseit! act as a calorie counter and weight and goal tracker. They even update patient's Facebook profiles on progress. 3. Free programmes such as habitforge.com can email users daily to encourage progress on their new health habits.
1. Some websites offer interactive tools to learn about portion sizes (e.g. http://www.webmd.com/diet/healthtool-portion-size-plate). 2. Companies such as Nutrawize and The Portion Plate offer modified plates to improve portion control by providing visual feedback regarding normal portion sizes.
1. Books and online resources such as Eat This, Not That can help one make informed choices about restaurant meals before heading out to eat. 2. Iphone applications such as Calorie Tracker by Livestrong.com allow easy access to restaurant calorie listings even while sitting in the restaurant.
Portion sizes of both food and drink have increased sharply in recent decades (29,30). Because total food consumption increases in proportion to portion sizes (31), controlling portions should be an important focus of weight management efforts. Meal replacement drinks and portion controlled entrees are one established means of assisting with portion control (32,33). These alternatives may enhance weight management through both increased protein content – which improves satiety – and visual cues teaching patients appropriate portion sizes. Another practical means of moderating portions is to reduce the size of flatware used by patients, as they have profound and largely subconscious influences on portion size selection. In a randomized study assigning participants to a combination of bowls and serving spoons varying in size, researchers found that those using the larger bowls served themselves on average 31% more ice cream, and the larger spoon users scooped an average of 14.5% more ice cream (34). Similarly, larger serving bowls at a Super Bowl party were associated with a 56% increase in snack consumption (translating into 142 calories more per person) (35).
Encouraging patients to merely eat less in the face of these ubiquitous food influences is a poor approach. Research on this topic is consistent in demonstrating that participants are rarely aware of the effects of external factors on their eating behaviour, instead attributing their eating to hunger and taste (36). This suggests that increasing patients' awareness of these factors and involving them in practical modification strategies in their eating environments is more likely to be helpful than instructions to simply eat less or eat only when hungry.
Restaurants are an increasingly common source for meals, with many Americans eating out several times per week (37). Observational studies indicate that the overweight and obese consume more meals out of the home than do healthy weight individuals (38). Although reducing restaurant patronage is a potentially beneficial tactic, a complementary method is to emphasize the adoption of new eating strategies in these settings. Research suggests that people who are overweight approach restaurant meals in different but modifiable ways. For example, in an observational study of randomly selected buffet diners, researchers reported that heavier patrons chose larger plates, ate more quickly and were more likely to clean their plates (39). Higher body mass index (BMI) patrons even chose different seating locations, more often sitting facing the buffet than in a booth compared with lower BMI patrons.
Even for patients who frequent restaurants offering healthier meal choices and make informed meal decisions based on nutrition information available from the restaurants themselves or online sources, over-eating risks are not eliminated. Calories contained in restaurant meals are often underestimated, with a 2010 study indicating that the typical food item contained 18% more calories than suggested by nutrition labels (40). In a standard 500-calorie restaurant meal, for example, the true caloric content is often closer to 600. A regular 18% underestimation in caloric intake on a per meal basis in an individual requiring 2000 calories per day for weight maintenance could lead to an annual weight gain exceeding 35 pounds.
Underestimations of calorie counts in restaurants and many grocery store foods are not coincidental; current Food and Drug Administration guidelines permit calorie reports to err by as much as 20% (http://www.fda.gov/Food/default.htm). Given this reality, patients can benefit from an increased awareness of new government guidelines regarding nutrition labelling in restaurants, which may improve their food choices (41,42).
Weight increases among Americans in recent decades are paralleled by reductions in sleep (43). Observational studies consistently demonstrate a relationship between obesity and shorter sleep duration (44). A 2008 meta-analysis of cross-sectional data on sleep duration and obesity risk reported obesity odds ratio of 1.55 (95% CI = 1.43 to 1.68; P < 0.001) for short vs. normal sleepers in adult populations among 45 pooled studies (45).
The potential benefits of promoting sleep hygiene to improve weight management efforts are possibly underestimated because of a lack of randomized research and absence of interventions showing that sleep changes can produce improvements in weight-related outcomes. Laboratory and treatment data are increasingly available on these issues, however. A number of laboratory sleep restriction studies (46,47) demonstrate that even a few days of imposed sleep reduction can significantly alter metabolic function and appetite hormone levels. These changes are reversed by the resumption of a normal sleep schedule. Imposed sleep impairment in a randomized crossover study was also associated with increased caloric intake, snacking and carbohydrate consumption over a 2-week period, with most of these behavioural changes manifesting in the evening and early morning hours (48). Furthermore, significant reductions in glucose tolerance and insulin sensitivity accompanied these patterns (49).
Obesity is strongly associated with obstructive sleep apnea (OSA) risk (50) and treatments appear to improve metabolic as well as sleep-specific endpoints. Continuous positive airway pressure (CPAP) treatment of sleep apnea, for example, can lower glucose levels (51) and improve insulin resistance (52,53). A well-controlled CPAP intervention among 22 OSA patients also showed significant reductions in visceral and subcutaneous fat accumulation following 6 months of treatment (54). These accumulating data are increasingly confirming that inadequate sleep creates a metabolic environment disposed to weight gain that is reversible with improved sleeping habits.
Americans view nearly 5 h of television per day (55), trailing only sleep and work in average daily time consumption (56). To the extent that television viewing contributes to weight gain, the annual time exposed to this influence (over 1800 h year−1) by typical patients is enormous. Encouragement from the PCP to make even small to moderate per cent reductions in television viewing translates potentially into hundreds of hours of time gained to spend in activities more favorable to weight management and related quality of life goals.
Observational studies indicate that television viewing patterns parallel the rising rates of obesity and diabetes among Americans (57). Increases in television viewing time predict 5-year waist circumference increases in both men and women (58). Laboratory research indicates that increases in both sedentary behaviour and food consumption are important mechanisms through which television viewing may dispose weight gain and unhealthy metabolic changes (57,59). The conclusions of studies such as these favour reducing total television viewing time as a strategy that may create additional opportunities for physical activity and reduced caloric intake (60).
Another line of research, however, suggests that the content of television programming may be an overlooked contributor to this relationship. For example, one study showed that participants consumed up to 45% more snack food when exposed to food commercials during television programming compared with the same programme without the food commercials (61), suggesting that dietary changes associated with television viewing may be a product of specific television content as much as total viewing time. Studies such as the latter suggest that weight-related benefits might be achieved even from modifications in television viewing habits or advertising regulations that do not reduce actual viewing time.
A number of promising results available from studies on child and adolescent populations indicate reductions in BMI and caloric intake (100–200 kcal d−1) can be achieved from interventions reducing television time (62). Studies involving adults have only recently become available. One study assigned overweight and obese adults to either a control group or a condition reducing television viewing by 50% (enforced by an electronic lock-out system) for 3 weeks. The reduced viewing time participants showed a significant increase in energy expenditure (119 kcal d−1) compared with baseline and a significant decrease in BMI (63). Participants in the control condition demonstrated no weight-related changes.
Practical behavioural weight management for the primary care provider
The weight management strategies advocated in this paper intentionally contrast with more typical approaches involving substantial changes in multiple behaviours. We instead encourage the PCP to collaborate with patients with the more modest goal of taking in fewer or expending more calories by an amount of just a couple of hundred per day. A consistent 200-calorie-a-day decrease can result in a 20-pound change in a year, a result carrying appreciable health benefits. We have presented evidence that seemingly small fluctuations in daily energy explain much of the weight gain experienced by patients, and reviewed a broad collection of studies to identify behavioural strategies that can reliably tip the energy consumption balance back in the favour of weight loss.
A weight management encounter with the PCP should contain elements of assessment, motivation and intervention. This may include obtaining information about the patient's lifestyle, helping identify ways in which weight loss can facilitate the patient's health and quality of life goals, and inquiring with the patient regarding the weight-related behaviours they see as most important to change and feel most capable of modifying. The contents of Tables 1 and 2 are intended to enhance this discussion by providing a range of application options for each behaviour. These efforts may be further facilitated by recommending quality self-help materials (64) that advocate the same small-scale philosophy to weight and health enhancement. Arguably the most useful initial behavioural change is to begin self-monitoring. Self-monitoring methods can be individualized to record a range of lifestyle targets (e.g. reduced sugary beverage consumption) (65) and can generate a wealth of knowledge to inform subsequent weight management efforts.
The reviewed approaches are complementary with one another, customizable to lifestyle circumstances, and measurable for tracking progress and adherence. They go beyond the rudimentary exercise and diet counselling message to identify precise areas PCPs may discuss with patients to achieve sensible activity and caloric reduction goals. The discussed strategies also have the benefit of requiring no other provider involvement outside the PCP and patient. However, this should not be read to suggest that the effectiveness of the strategies could not be enhanced with multidisciplinary team assistance or that the involvement of specialized providers is not important among patients with advanced symptoms (e.g. sleep apnea, morbid obesity, eating disorders, etc.).
Outside these specific methods, we have argued that the most important ingredients to weight management success for the PCP is helping patients to adopt realistic expectations (e.g. aiming, at least initially, for a 5–10% weight loss; 14) regarding weight management efforts and encouraging a perspective of emphasizing small-scale changes and consistency over extreme short-term efforts. This is not implied to be an easy task, although established ‘Motivational Interviewing’ techniques for improving health providers' efforts towards enabling behaviour change are available and highly recommended (66). Without such a fundamental change in perspective, behavioural weight management strategies are often misguided from the beginning and rarely achieve sustainable progress at a rate matching patient expectations.
Conflict of Interest Statement
The authorship team affirms that no conflicts of interest were present in the development of this manuscript.
No grant funding was involved in the preparation of this manuscript.