Best Practice Guidelines on Informed Consent for Weight Loss Surgery Patients

Objective: To provide evidence‐based guidelines on informed consent and the education that underlies it for legally competent, severely obese weight loss surgery (WLS) patients. Research Methods and Procedures: We conducted a systematic review of the scientific literature published on MEDLINE between 1984 and 2004. Three articles focused on informed consent for WLS; none was based on empirical studies. We summarized each paper and assigned evidence categories according to a grading system derived from established evidence‐based models. We also relied on informed consent and educational materials from six WLS programs in Massachusetts. All evidence is Category D. Recommendations were based on a review of the available literature, informed consent materials from WLS programs, and expert opinion. Results: This Task Group found that the informed consent process contributes to long‐term outcome in multiple ways but is governed by limited legal requirements. We focused our report on the legal and ethical issues related to informed consent, i.e., disclosure vs. comprehension. Recommendations centered on the importance of assessing patient comprehension of informed consent materials, the content of those materials, and the use of active teaching/learning techniques to promote understanding. Discussion: Although demonstrated comprehension is not a legal requirement for informed consent in Massachusetts or other states, the members of this Task Group found that the best interests of WLS patients, providers, and facilities are served when clinicians engage patients in active learning and collaborative decision making.     

Effect of weight loss on predicted cardiovascular risk: change in cardiac risk after bariatric surgery

Objective: Our goal was to assess the effect of bariatric surgery on cardiovascular risk estimations of preventable, long‐term adverse outcomes. Research Methods and Procedures: We performed a population‐based, historical cohort study between 1990 and 2003 of 197 consecutive patients from Olmsted County, MN, with Class II to III obesity (defined as BMI ≥35 kg/m²) treated with Roux‐en‐Y gastric bypass and 163 non‐operative patients assessed in a weight‐reduction program. We used the observed change in cardiovascular risk factors and risk models derived from data from the National Health and Nutrition Examination Survey (NHANES) I and the NHANES I Epidemiological Follow‐up Study (NHEFS) to calculate the predicted impact on cardiovascular events and mortality for the operative and non‐operative groups. Results: Mean follow‐up was 3.3 years. Hypertension, diabetes, and dyslipidemia all improved after bariatric surgery. The estimated 10‐year risk for cardiovascular events for the operative group decreased from 37% at baseline to 18% at follow‐up, while the estimated risk for the non‐operative group did not change from 30% at baseline to 30% at follow‐up. Risk modeling to predict 10‐year outcomes estimated 4 overall deaths and 16 cardiovascular events prevented by bariatric surgery per 100 patients compared with the non‐operative group. Conclusions: Bariatric surgery induces an improvement in cardiovascular risk factors in patients with Class II to III obesity. Weight loss predicts a major, 10‐year reduction in cardiovascular events and deaths. Bariatric surgery should be considered as an alternative approach to reduce cardiovascular risk in patients with Class II to III obesity.     

Behavioral and Psychological Factors in the Assessment and Treatment of Obesity Surgery Patients

Objective: To provide evidence‐based guidelines on the psychological and behavioral screening of weight loss surgery (WLS) candidates and the impact of psychosocial factors on behavior change after gastric bypass surgery. Research Methods and Procedures: The members of the Behavioral and Psychological subgroup of the Multidisciplinary Care Task Group conducted searches of MEDLINE and PubMed for articles related to WLS, behavior changes, and mental health, including quality of life (QOL) and behavior modification. Pertinent abstracts and literature were reviewed for references. A total of 198 abstracts were identified; 17 papers were reviewed in detail. Search periods were from 1980 to 2004. Results: We found a high incidence of depression, negative body image, eating disorders, and low QOL in severely obese patients. Our task subgroup recommended that all WLS candidates be evaluated by a licensed mental health care provider (i.e., psychiatrist, psychologist, or social worker), experienced in the treatment of severely obese patients and working within the context of a multidisciplinary care team. We also recommended development of pre‐ and postsurgical treatment plans that address psychosocial contraindications for WLS and potential barriers to postoperative success. Discussion: The psychological consequences of obesity can range from lowered self‐esteem to clinical depression. Rates of anxiety and depression are three to four times higher among obese individuals than among their leaner peers. A comprehensive multidisciplinary program that incorporates psychological and behavior change services can be of critical benefit in enhancing compliance, outcome, and QOL in WLS patients.     

Informed consent and nudging

In order to avoid patient abuse, under normal situations before performing a medical intervention on a patient, a physician must obtain informed consent from that patient, where to give genuine informed consent a patient must be competent, understand her condition, her options and their expected risks and benefits, and must expressly consent to one of those options. However, many patients refrain from the option that their physician believes to be best, and many physicians worry that their patients make irrational healthcare decisions, hindering their ability to provide efficient healthcare for their patients. Some philosophers have proposed a solution to this problem: they advocate that physicians nudge their patients to steer them towards their physician's preferred option. A nudge is any influence designed to predictably alter a person's behavior without limiting their options or giving them reasons to act. Proponents of nudging contend that nudges are consistent with obtaining informed consent. Here I argue that nudging is incompatible with genuine informed consent, as it violates a physician's obligation to tell their patients the truth, the whole truth, and nothing but the truth during adequate disclosure.     

The Impact of Obesity on Primary Care Visits

Objective: To investigate the influence of patient obesity on primary care physician practice style. Research Methods and Procedures: This was a randomized, prospective study of 509 patients assigned for care by 105 primary care resident physicians. Patient data collected included sociodemographic information, self‐reported health status (Medical Outcomes Study Short Form‐36), evaluation for depression (Beck Depression Index), and satisfaction. Height and weight were measured to calculate the BMI. Videotapes of the visits were analyzed using the Davis Observation Code (DOC). Results: Regression equations were estimated relating obesity to visit length, each of the 20 individual DOC codes, and the six DOC Physician Practice Behavior Clusters, controlling for patient health status and sociodemographics. Obesity was not significantly associated with the length of the visit, but influenced what happened during the visit. Physicians spent less time educating obese patients about their health (p = 0.0062) and more time discussing exercise (p = 0.0075). Obesity was not related to discussions regarding nutrition. Physicians spent a greater portion of the visit on technical tasks when the patient was obese (p = 0.0528). Mean pre‐visit general satisfaction for obese patients was significantly lower than for non‐obese patients (p = 0.0069); however, there was no difference in post‐visit patient satisfaction. Discussion: Patient obesity impacts the medical visit. Further research can promote a greater understanding of the relationships between obese patients and their physicians.     

A Randomised Controlled Trial of Consent Procedures for the Use of Residual Tissues for Medical Research: Preferences of and Implications for Patients,Research and Clinical Practice

Background

Despite much debate, there is little evidence on consequences of consent procedures for residual tissue use. Here, we investigated these consequences for the availability of residual tissue for medical research, clinical practice, and patient informedness.

Methods

We conducted a randomised clinical trial with three arms in six hospitals. Participants, patients from whom tissue had been removed for diagnosis or treatment, were randomised to one of three arms: informed consent, an opt-out procedure with active information provision (opt-out plus), and an opt-out procedure without active information provision. Participants received a questionnaire six weeks post-intervention; a subsample of respondents was interviewed. Health care providers completed a pre- and post-intervention questionnaire. We assessed percentage of residual tissue samples available for medical research, and patient and health care provider satisfaction and preference. Health care providers and outcome assessors could not be blinded.

Results

We randomised 1,319 patients, 440 in the informed consent, 434 in the opt-out plus, and 445 in the opt-out arm; respectively 60.7%, 100%, and 99.8% of patients’ tissue samples could be used for medical research. Of the questionnaire respondents (N = 224, 207, and 214 in the informed consent, opt-out plus, and opt-out arms), 71%, 69%, and 31%, respectively, indicated being (very) well informed. By questionnaire, the majority (53%) indicated a preference for informed consent, whereas by interview, most indicated a preference for opt-out plus (37%). Health care providers (N = 35) were more likely to be (very) satisfied with opt-out plus than with informed consent (p = 0.002) or opt-out (p = 0.039); the majority (66%) preferred opt-out plus.

Conclusion

We conclude that opt-out with information (opt-out plus) is the best choice to balance the consequences for medical research, patients, and clinical practice, and is therefore the most optimal consent procedure for residual tissue use in Dutch hospitals.

Trial Registration

Dutch Trial Register NTR2982     

Development and Evaluation of Patient‐Centered Software for a Weight‐Management Clinic

Objective: To describe a weight‐management clinic software system and to report on its preliminary evaluation. Research Methods and Procedures: The software system standardizes the collection of relevant patient information from an initial medical assessment, weekly clinic visits, and laboratory testing protocol of a medically supervised proprietary meal‐replacement program in a university‐based referral clinic. It then generates monthly patient feedback reports with graphs of clinical and laboratory parameters to support a patient‐centered approach to weight management. After patients and clinic physicians review the data to ensure accuracy, the database is used for subsequent patient feedback reports, reports to referring physicians, quality assurance, and research. Clinic physicians and referring physicians were asked to rate their acceptance of the system. In addition, in a retrospective analysis of data generated by the system, outcomes for patients who received system‐generated feedback (n = 620) were compared with those who participated in the program before the introduction of feedback (n = 130). Results: Clinic and referring physicians reported that they had high overall satisfaction with the software and that the system saved them time, and the latter group reported that it decreased laboratory use. Regarding patients, the feedback group had lower dropout rates in the latter half of the program, better rates of attendance, completion of laboratory tests, and weight loss after 8 weeks. Discussion: The software seems to facilitate the effectiveness of the treatment protocol for obesity and generates a high‐quality database for patient care, clinic administration, quality assurance, and research purposes.     

Modeling the Impact of Adjustable Gastric Banding on Survival in Patients with Morbid Obesity

Objective: Morbid obesity is associated with premature death. Adjustable gastric banding may lead to substantial weight loss in patients with morbid obesity. Little is known about the impact of weight loss on survival after adjustable gastric banding. We therefore developed a mathematical model to estimate life expectancy in patients with a body mass index (BMI) ≥40 kg/m² undergoing bariatric surgery. Research Methods and Procedures: We developed a nonhomogeneous Markov chain consisting of five states: the absorbing state (“dead”) and the four recurrent states BMI ≥40 kg/m², BMI 36 to 39 kg/m², BMI 32 to 35 kg/m², and BMI 25 to 31 kg/m². Scenarios of weight loss and age‐ and sex‐dependent risk of death, as well as BMI‐dependent excess mortality were extracted from life tables and published literature. All patients entered the model through the state of BMI ≥40 kg/m². Results: In men aged either 18 or 65 years at the time of surgery, who moved from the state BMI ≥40 kg/m² to the next lower state of BMI 36 to 39 kg/m², life expectancy increased by 3 and 0.7 years, respectively. In women aged either 18 or 65 years at the time of surgery, who moved from the state BMI ≥40 kg/m² to the next lower state BMI 36 to 39 kg/m², life expectancy increased by 4.5 and 2.6 years, respectively. Weight loss to lower BMI strata resulted in further gains of life expectancy in both men and women. Discussion: Within the limitations of the modeling study, adjustable gastric banding in patients with morbid obesity may substantially increase life expectancy.     

Coding and Reimbursement for Weight Loss Surgery: Best Practice Recommendations

Objective: To review the use and usefulness of billing codes for services related to weight loss surgery (WLS) and to examine third party reimbursement policies for these services. Research Methods and Procedures: The Task Group carried out a systematic search of MEDLINE, the Internet, and the trade press for publications on WLS, coding, reimbursement, and coding and reimbursement policy. Twenty‐eight articles were each reviewed and graded using a system based on established evidence‐based models. The Massachusetts Dietetics Association provided reimbursement data for nutrition services. Three suppliers of laparoscopic WLS equipment provided summaries of coding and reimbursement information. WLS program directors were surveyed for information on use of procedure codes related to WLS. Results: Recommendations focused on correcting or improving on the current lack of congruity among coding practices, reimbursement policies, and accepted clinical practice; lack of uniform coding and reimbursement data across institutions; inconsistent and/or inaccurate diagnostic and billing codes; inconsistent insurance reimbursement criteria; and inability to leverage reimbursement and coding data to track outcomes, identify best practices, and perform accurate risk‐benefit analyses. Discussion: Rapid changes in the prevalence of obesity, our understanding of its clinical impact, and the technologies for surgical treatment have yet to be adequately reflected in coding, coverage, and reimbursement policies. Issues identified as key to effective change include improved characterization of the risks, benefits, and costs of WLS; anticipation and monitoring of technological advances; encouragement of consistent patterns of insurance coverage; and promotion of billing codes for WLS procedures that facilitate accurate tracking of clinical use and outcomes.     

Informed Consent in Direct‐to‐Consumer Personal Genome Testing: The Outline of A Model between Specific and Generic Consent

Broad genome‐wide testing is increasingly finding its way to the public through the online direct‐to‐consumer marketing of so‐called personal genome tests. Personal genome tests estimate genetic susceptibilities to multiple diseases and other phenotypic traits simultaneously. Providers commonly make use of Terms of Service agreements rather than informed consent procedures. However, to protect consumers from the potential physical, psychological and social harms associated with personal genome testing and to promote autonomous decision‐making with regard to the testing offer, we argue that current practices of information provision are insufficient and that there is a place – and a need – for informed consent in personal genome testing, also when it is offered commercially. The increasing quantity, complexity and diversity of most testing offers, however, pose challenges for information provision and informed consent. Both specific and generic models for informed consent fail to meet its moral aims when applied to personal genome testing. Consumers should be enabled to know the limitations, risks and implications of personal genome testing and should be given control over the genetic information they do or do not wish to obtain. We present the outline of a new model for informed consent which can meet both the norm of providing sufficient information and the norm of providing understandable information. The model can be used for personal genome testing, but will also be applicable to other, future forms of broad genetic testing or screening in commercial and clinical settings.     

Criteria for Patient Selection and Multidisciplinary Evaluation and Treatment of the Weight Loss Surgery Patient

Objective: To provide evidence‐based guidelines for patient selection and to recommend the medical and nutritional aspects of multidisciplinary care required to minimize perioperative and postoperative risks in patients with severe obesity who undergo weight loss surgery (WLS). Research Methods and Procedures: Members of the Multidisciplinary Care Task Group conducted searches of MEDLINE and PubMed for articles related to WLS in general and medical and nutritional care in particular. Pertinent abstracts and literature were reviewed for references. Multiple searches were carried out for various aspects of multidisciplinary care published between 1980 and 2004. A total of 3000 abstracts were identified; 242 were reviewed in detail. Results: We recommended multidisciplinary screening of WLS patients to ensure appropriate selection; preoperative assessment for cardiovascular, pulmonary, gastrointestinal, endocrine, and other obesity‐related diseases associated with increased risk for complications or mortality; preoperative weight loss and cessation of smoking; perioperative prophylaxis for deep vein thrombosis and pulmonary embolism (PE); preoperative and postoperative education and counseling by a registered dietitian; and a well‐defined postsurgical diet progression. Discussion: Obesity‐related diseases are often undiagnosed before WLS, putting patients at increased risk for complications and/or early mortality. Multidisciplinary assessment and care to minimize short‐ and long‐term risks include: comprehensive medical screening; appropriate pre‐, peri‐, and postoperative preparation; collaboration with multiple patient care disciplines (e.g., anesthesiology, pulmonary medicine, cardiology, and psychology); and long‐term nutrition education/counseling.     

Introduction of a surgical Black Box system in a hybrid angiosuite: Challenges and opportunities

PurposeIn laparoscopy, the Operating Room Black Box® (ORBB) provides insights into operative performance to improve patient safety. This technology may also enhance endovascular surgical practice; however, the use of a C-arm and X-rays pose important challenges, hindering transferability to an endovascular context. We describe the first implementation of ORBB technology in a hybrid angiosuite and illustrate its value in evaluating surgeons’ radiation safety, technical and non-technical performance.MethodsTeam members (surgeons, nurses, anaesthesiologists) and stakeholders were informed during several information sessions. Together with teams from Surgical Safety Technologies (Toronto, Canada), an implementation plan was developed, and video-evaluation frameworks were chosen.Radiation safety was assessed using dose measurements and video-evaluation of safety-related behaviours. Technical performance was assessed using ‘global’ (GRS) and ‘procedure-specific’ (PRS) rating scales and the ‘EndoVascular Aortic Repair Assessment of Technical Expertise’ (EVARATE) framework. Surgeons’ non-technical skills were assessed with the NOTSS framework.ResultsThe system captures Audio-visual data from four ceiling-mounted cameras, three ceiling-array microphones, the fluoroscopy screen and anaesthesia monitor. After patient and team consent, an elective endovascular aneurysm repair was successfully analysed. Dose-Area-Product and Air Kerma were 71094 mGy.cm² and 270 mGy, respectively. Behavioural analysis revealed deficiencies in stepping back and radiation safety communication. Technical skill assessment was feasible: GRS: 29/40; ‘PRS’: 27/35; EVARATE: 29/35. Non-technical analysis highlighted surgeons’ leadership qualities.ConclusionAn innovative data capture platform has been successfully installed to evaluate overall performance during endovascular procedures. This technology may facilitate identification of (radiation) safety-related errors and instigate educational interventions based on real-world issues.     

On Taylor's justification of medical informed consent

In contemporary Western biomedical ethics, informed consent practices are commonly justified in terms of the intrinsic value of patient autonomy. James Stacey Taylor maintains that this conception of the moral grounding of medical informed consent is mistaken. On the basis of his reasoning to that effect, Taylor argues that medical informed consent is justified by the instrumental value of personal autonomy. In this article, I examine whether Taylor's justification of medical informed consent is plausible.     

An approach that integrates patient education and informed consent in breast augmentation

Informed consent requires surgeons to provide information about all available alternatives and their associated risks and tradeoffs to every prospective breast augmentation patient. The informed patient and surgeon then make decisions based on the information the patient has received, clinical parameters that may affect those decisions, and the patient's willingness to accept specific risks and tradeoffs. During the authors' 22 years of clinical practice, substantial changes have occurred in the requirements for adequate informed consent and the methods of ensuring that patients receive it.The numbers of alternatives for augmentation and the relative benefits and risks of each method have changed substantially over the past two decades. Four specific areas of postoperative issues stimulated major changes in the authors' approach to patient education and informed consent: 1) questions or dissatisfaction with implant size postoperatively, 2) questions about financial responsibility for costs associated with untoward events requiring reoperation postoperatively including capsular contracture or other problems, 3) spouses or other concerned parties rendering opinions postoperatively when they had not been involved in the informed consent process, and 4) criteria for whether reoperations were indicated, how many were indicated, and when implant removal without replacement might be most logical.This paper describes an approach that integrates patient education and informed consent in stages by 1) providing detailed, highly specific written and verbal information, 2) utilizing a staged approach to education and informed consent that provides information and requires simultaneous, informed consent in stages, 3) repeating each critical topic at least two or three times during the process, requiring repetitive written documentation by the patient on at least three different occasions, 4) emphasizing patient accountability for choices selected, and 5) organizing the education and informed consent process so that it is clinically practical and also increases thoroughness and documentation while conserving surgeon time.This staged, integrated system of patient education and informed consent uses a comprehensive set of informed consent documents that are available for downloading from the Plastic and Reconstructive Surgery Web site (www.plasreconsurg.org).Before incorporating any of the informed consent documents or statements reported in this paper, each surgeon should seek review by the surgeon's malpractice insurance carrier and by appropriate legal counsel to ensure compliance with state and federal laws applicable to the surgeon's practice. These documents have evolved to prospectively address patient management issues that have occurred over the authors' 22-year experience in augmentation. The documents are not endorsed by ASPS and do not necessarily represent the views of ASPS.     

Randomised comparison of procedures for obtaining informed consent in clinical trials of treatment for cancer.

Methods of obtaining informed consent have evolved differently in Western countries without substantive information on the impact of these different practices on the patients. A randomised study was performed to compare two commonly adopted methods of seeking consent to randomised treatment: an individual approach at the discretion of each doctor and a uniform policy of total disclosure of all relevant information. The impact of both consent procedures on the patient''s understanding and anxiety levels and on the doctor-patient relationship was assessed by means of a questionnaire given soon after the consent interview. Fifty seven patients were assigned at random to two groups: to 29 patients an individual approach to seeking consent was adopted and to 28 patients all relevant information was given. Seven patients refused consent to randomised treatment, with slightly more refusals by patients in the total disclosure group (5 v 2, p = 0.25). The main effects of total disclosure of all information compared with an individual approach to seeking consent were: a better understanding of treatment and side effects and of research aspects of the treatments; less willingness to agree to randomised treatment; and increased anxiety. No significant differences were found in patients'' perceptions of the doctor-patient relationship. A repeat questionnaire given three to four weeks later no longer showed significant differences between the two groups.     

Clinical practice guidelines for the perioperative nutritional,metabolic, and nonsurgical support of the bariatric surgery patient—2013 update: Cosponsored by american association of clinical endocrinologists,The obesity society,and american society for metabolic & bariatric surgery*

Abstract:

The development of these updated guidelines was commissioned by the AACE, TOS, and ASMBS Board of Directors and adheres to the AACE 2010 protocol for standardized production of clinical practice guidelines (CPG). Each recommendation was re‐evaluated and updated based on the evidence and subjective factors per protocol. Examples of expanded topics in this update include: the roles of sleeve gastrectomy, bariatric surgery in patients with type‐2 diabetes, bariatric surgery for patients with mild obesity, copper deficiency, informed consent, and behavioral issues. There are 74 recommendations (of which 56 are revised and 2 are new) in this 2013 update, compared with 164 original recommendations in 2008. There are 403 citations, of which 33 (8.2%) are EL 1, 131 (32.5%) are EL 2, 170 (42.2%) are EL 3, and 69 (17.1%) are EL 4. There is a relatively high proportion (40.4%) of strong (EL 1 and 2) studies, compared with only 16.5% in the 2008 AACE‐TOS‐ASMBS CPG. These updated guidelines reflect recent additions to the evidence base. Bariatric surgery remains a safe and effective intervention for select patients with obesity. A team approach to perioperative care is mandatory with special attention to nutritional and metabolic issues.     

Participant informed consent in cluster randomized trials: review

Background

The Nuremberg code defines the general ethical framework of medical research with participant consent as its cornerstone. In cluster randomized trials (CRT), obtaining participant informed consent raises logistic and methodologic concerns. First, with randomization of large clusters such as geographical areas, obtaining individual informed consent may be impossible. Second, participants in randomized clusters cannot avoid certain interventions, which implies that participant informed consent refers only to data collection, not administration of an intervention. Third, complete participant information may be a source of selection bias, which then raises methodological concerns. We assessed whether participant informed consent was required in such trials, which type of consent was required, and whether the trial was at risk of selection bias because of the very nature of participant information.

Methods and Findings

We systematically reviewed all reports of CRT published in MEDLINE in 2008 and surveyed corresponding authors regarding the nature of the informed consent and the process of participant inclusion. We identified 173 reports and obtained an answer from 113 authors (65.3%). In total, 23.7% of the reports lacked information on ethics committee approval or participant consent, 53.1% of authors declared that participant consent was for data collection only and 58.5% that the group allocation was not specified for participants. The process of recruitment (chronology of participant recruitment with regard to cluster randomization) was rarely reported, and we estimated that only 56.6% of the trials were free of potential selection bias.

Conclusions

For CRTs, the reporting of ethics committee approval and participant informed consent is less than optimal. Reports should describe whether participants consented for administration of an intervention and/or data collection. Finally, the process of participant recruitment should be fully described (namely, whether participants were informed of the allocation group before being recruited) for a better appraisal of the risk of selection bias.     

The perceived effectiveness of continuing care and group support in the long-term self-help treatment of obesity

Objective : Obesity is increasingly considered a chronic disease requiring continuing care, but professional long‐term treatment for most patients is not available. This study examined treatment recipients’ perception of the effectiveness of different components of a group self‐help, continuing‐care treatment program for obesity. Research Methods and Procedures : Members (n = 120) and volunteer leaders (n = 66) of a self‐help, continuing‐care treatment program of previously demonstrated effectiveness (mean treatment duration, 40.6 months; mean weight lost, 14.1 kg) rated how helpful and effective they found the various therapeutic strategies used by this program. The strategies examined were continuing care, group support, behavior therapy, motivational enhancement strategies involving positive reinforcement, and motivational enhancement strategies involving punishment. Results : The single most highly valued aspect of treatment was the provision of continuing care, followed by group support. Greater success at achieving one's goal weight was associated with perceptions of greater effectiveness of the program's strategies overall (r = 0.219, p < 0.005), of continuing care (r = 0.225, p < 0.005), and of positive reinforcement strategies (r = 0.223, p < 0.01). Participants who had successfully attained their goal weight perceived behavior therapy strategies as more effective than did participants who had not reached their goal weight [t (170) = 2.93, p < 0.005]. Discussion : The high ratings given to continuing care and group support strategies indicate the acceptability of supportive self‐help treatment for obesity administered over the long term. The findings suggest that continuing care and group support should be made available to participants in the self‐help treatment of obesity.     

Ambulatory Management of Childhood Obesity

Objective: Childhood obesity is one of the most challenging issues facing healthcare providers today. The aims of this study were to describe the ambulatory management of childhood obesity by pediatricians (PDs) and family physicians (FPs) and to evaluate knowledge of and adherence to published recommendations. Research Methods and Procedures: A 42‐item, self‐administered questionnaire was mailed to 1207 randomly selected primary care physicians (PDs = 700, FPs = 507) between September 2001 and January 2002. Results: Of 339 (28%) responses, 287 were eligible (PDs = 213, FPs = 74). Most respondents were in group or solo practice (87%) in a suburban or urban, non‐inner city location (67%). The average age was 48 years (range = 31 to 85 years), and the mean years in practice was 17 (range = 1 to 55 years). Nineteen percent of physicians were aware of national recommendations. Three percent of physicians reported adherence to all recommendations. Knowledge of recommendations was not associated with a greater likelihood of adherence. However, physicians who were aware of recommendations were more likely to have positive attitudes about personal counseling ability (odds ratio = 2.4, confidence interval = 1.3 to 4.4) and the overall efficacy of obesity counseling (odds ratio = 4.3, confidence interval = 1.7 to 10.8). Poor patient motivation, patient noncompliance, and treatment futility were perceived as the most frequently encountered barriers to obesity treatment. Discussion: Most physicians are not aware of or adherent to national recommendations regarding childhood obesity. Awareness of recommendations was associated with more positive attitudes about personal counseling ability and the effectiveness of obesity counseling in general.