Despite national guidelines for primary care physicians (PCPs) to counsel their patients to lose weight, evidence suggests that most patients do not receive recommended obesity care^1-2. Potential physician-related reasons for this sub-optimal care include: insufficient time, negative attitudes towards obese patients; and general beliefs that obese patients cannot lose weight^3-8.

The Health Belief Model puts forward the idea that an individual’s views and attitudes towards health influence their choices and behaviors⁹. However, limited attention has focused on whether physician beliefs about obesity impact their care of heavier patients. For other health conditions, such as diabetes and hypertension, there is evidence that physician beliefs about the causes of a disease may be as important as physician knowledge in determining practices like prescribing behavior^10-12. Obesity care may improve if evidence-based clinical guidelines on obesity management could align physician beliefs with recommended practice behaviors.

Relationship between physician beliefs and counseling habits for obese patients

In this study, we evaluated whether PCP beliefs about the causes of obesity are associated with actionable topics on which physicians counsel their patients. We hypothesized that physician beliefs about the causes of obesity would be associated with the type and frequency of nutritional counseling; in particular, the belief that modifiable diet-related factors cause obesity would be positively associated with nutritional counseling while the belief that immutable biological factors that cause obesity would not.

To accomplish this, we analyzed a national cross-sectional internetbased survey of 500 U.S. PCPs collected between February and March 2011. A total of 2010 invitations were sent at random to members of the Epocrates Honors panel, an opt-in panel of 145,000 US physicians. They received a $25 incentive to participate; 58 invitations were undeliverable. We had a response rate of 25.6%.

Using a list of five possible causes of obesity, we asked respondents how important they felt each item was, using a scale of very important, somewhat important, not very important, and not at all important. We then assessed nutritional counseling habits by asking how frequently they provided five different types of nutritional counseling to their obese patients, using a scale of very frequently, somewhat frequently, not very frequently, or not at all frequently.

Physician beliefs about the causes of obesity is associated with providing specific nutritional recommendations

PCPs that identified overconsumption of food as a very important cause of obesity had significantly greater odds of counseling patients to reduce portion sizes (OR 3.40; 95%CI: 1.73–6.68) and to avoid high calorie ingredients when cooking (OR 2.16; 95%CI: 1.07–4.33).

Physicians who believed that restaurant/fast food eating was a very important cause of obesity had significantly greater odds of counseling patients to avoid high calorie menu items outside the home (OR 1.93; 95%CI: 1.20–3.11).

Physicians who reported that sugar-sweetened beverages were a very important cause of obesity had significantly greater odds of counseling their obese patients to reduce consumption (OR 5.99; 95%CI: 3.53–10.17).

Physicians who believed that biological factors were the most important causes of obesity showed no association with nutritional counseling practices.

Our study had limitations, including a cross-sectional design that does not allow us to make causal inferences and our reliance on physician self-reporting. However, this is the first study that has explored the relationship between physician beliefs and counseling practices for obese patients, and further research should be undertaken to explore this subject further.