Preventive Medicine Reports 14 (2019) 100812

Contents lists available at ScienceDirect

Preventive Medicine Reports

journal homepage: www.elsevier.com/locate/pmedr

Review Article

Health advice and education given to overweight patients by primary care

doctors and nurses: A scoping literature review
⁎
Kristina Walsh , Carol Grech, Kathy Hill
School of Nursing and Midwifery, the University of South Australia, Australia

A R T I C LE I N FO A B S T R A C T

Keywords: Health advice for overweight patients in primary care has been a focus of obesity guidelines. Primary care
Health advice doctors and nurses are well placed to provide evidence based preventive health advice. This literature review
Health prevention addressed two research questions: ‘When do primary care doctors and nurses provide health advice for weight
Obese management?’ and ‘What health advice is provided to overweight patients in primary care settings?’
Overweight
The study was conducted in the first half of 2018 and followed Arksey and O'Malley (2005) five stage fra-
BMI
mework to conduct a comprehensive scoping review. The following databases were searched: Emcare, Ovid,
General practitioner
GP Embase, The Cochrane library, Proquest family health, Health source (nursing academic), Joanna Briggs
Nurse Institute EBP database, Medline, PubMed, Rural and remote, Proquest (nursing and allied health) and TRIP using
Practice nurse search term parameters. Two hundred and forty-eight (248) articles were located and screened by two reviewers.
Primary care Twenty-three research papers met the criteria and data were analysed using a content analysis method. The
results show that primary care doctors and nurses are more likely to give advice as BMI increases and often miss
opportunities to discuss weight with overweight patients. Body Mass Index (BMI) is often wrongly categorised as
overweight, when in fact it is in the range of obese, or not recorded and when health advice is given, it can be of
poor quality. Few studies on this topic included people under 40 years, practice nurses as the focus and those
with a BMI of 25–29.9 without a risk factor. A ‘toolkit’ approach to improve advice and adherence to evidence
based guidelines should be explored in future research.

1. Introduction 1.1. Body Mass Index and weight status

Preventing excessive weight gain and the management of over- A popular measure for classifying overweight and obese adults is the
weight conditions has been the subject of government guidelines and Body Mass Index (BMI) which is, weight in kilograms, divided by the
research projects in recent years. Worldwide obesity has nearly tripled square of height in meters (Australian Government and Australian
since 1975 (World Health Organisation, 2017). WHO (2017) define Institute of Health and Welfare, 2017; Australian Government
overweight and obesity as: “Abnormal or excessive fat accumulation Department of Health and National Health and Medical Research
that may impair health.” Overweight and obesity are of concern in Council, 2013; World Health Organisation, 2017). Adults with a BMI
many countries throughout the world causing more deaths than being equal to or > 25.0 are considered overweight and adults with a BMI
underweight (World Health Organisation, 2017). This largely pre- equal to or > 30.0 are considered obese (WHO, 2017). However, var-
ventable health concern has many associated conditions including, iations do occur in the guidance regarding the classification of obesity
cardiovascular disease, heart disease, stroke, diabetes, musculoskeletal (Australian Government Department of Health, 2009) and a BMI of
disorders and some cancers (Australian Government Department of 25.0–30.0 is considered pre-obese. While BMI is widely used in Aus-
Health and National Health and Medical Research Council, 2013; tralia to monitor weight (Australian Government and Australian
National institute for Health and Clinical excellence, 2006; World Institute of Health and Welfare, 2017), the parameters of pre-obese are
Health Organisation, 2017). not necessarily clearly applied in primary health practice as a trigger for
health advice and intervention.
In 2014–15, almost two in three Australian adults were overweight
or obese. Australian Institute of Health and Welfare (AIHW) data

⁎
Corresponding author.
E-mail address: [email protected] (K. Walsh).

https://doi.org/10.1016/j.pmedr.2019.01.016
Received 3 July 2018; Received in revised form 17 January 2019; Accepted 23 January 2019
Available online 25 January 2019
2211-3355/ © 2019 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/BY-NC-ND/4.0/).
K. Walsh et al. Preventive Medicine Reports 14 (2019) 100812

indicate that 19% more Australians were obese in 2014–15 than in 2. Methods
1995 (AIHW 2017). This increasing prevalence of obesity and its as-
sociated comorbidities has a financial impact on the Australian health Peters et al. (2017) guidance for population, concept and context
system. In 2008 the overall cost of obesity to Australian society and (PCC) was used to develop the title of this review and its related re-
governments was estimated to be 58.2 billion. This includes lost pro- search questions. Population (P) in this case is overweight adults,
ductivity, health system and carer costs (https://www.nhmrc.gov.au/ concept (C) is health advice provided by doctors and nurses, and the
health-topics/obesity-and-overweight). Decreasing the burden of over- context (C) is health advice provided in primary health encounters. We
weight and obesity has become a health priority in Australia (AIHW identified two questions for the study:
2017).
In response to the ‘obesity epidemic’, many nations have developed 1. When do primary care doctors and nurses provide health advice
policies and guidelines to assist in the early identification and man- relating to weight management?
agement of obesity. One example is the National Institute of Clinical 2. What health advice is provided to overweight patients by doctors
Excellence guidelines ‘Obesity management in primary care’ (2006) and nurses in primary care settings?
from the United Kingdom (UK). These are aimed at primary health
practitioners such as general practitioners and practice nurses because A scoping review method was chosen for this research as it allowed
they are considered the first point of care for overweight and obese us to delve deeper ‘beyond effectiveness’ (Peters et al., 2017) which is
individuals (Australian Government Department of Health, 2009; the focus of a systematic review of quantitative literature. The com-
National Health and Medical Research Council, 2013; National institute plexity of weight management by health professionals is often the
for Health and Clinical excellence, 2006). Their position within the subject of research from a qualitative or mixed methodology, which is
community setting enables them to identify, assist and treat individuals, considered to be a potential source of credible evidence (Peters et al.,
and relay important health messages to promote a healthy lifestyle 2017).
(National institute for Health and Clinical excellence, 2006; National Grant and Booth (2009 p.95) refer to a scoping study as a “pre-
Health and Medical Research Council, 2013). liminary assessment of potential size and scope of research literature”
Similarly, the Government of Canada & Research and CIoH (2010)
1.2. Primary health care and the roles of practitioners in early prevention describe a scoping review as a project to systematically map literature
available on a topic in order to identify concepts, theories, evidence and
In 2013, the NHMRC issued clinical practice guidelines, offering gaps within current research. They express the notion that this type of
approaches to weight management in primary health care (National study can be used to assess the feasibility of a full synthesis, which may
Health and Medical Research Council, 2013). The scope of these be a concern due to lack of literature available or a vast amount of
guidelines is to promote weight assessment, and give specific advice on diverse literature (Government of Canada & Research and CIoH, 2010).
weight management when an adult's BMI is > 25.0. The NHMRC This interpretation of a scoping review highlights the usefulness of
guidelines (National Health and Medical Research Council, 2013) em- this kind of review for the broad and complex topic of health advice
phasised that the first point of care for the identification of overweight given to overweight patients in primary care. A scoping review allows
and obesity is at the primary health level as articulated in the NICE different kinds of current literature to be explored and examined
Guidelines (National institute for Health and Clinical excellence, 2006). (Daviset al., 2009). Strengths and weaknesses in the literature can be
The NHMRC (2013) also refer to the role of general practitioners and established and this may inform further research and development
nurses working in the community to identify, assist and treat in- opportunities.
dividuals, while relaying positive health and lifestyle messages The complex nature of offering health advice to overweight patients
(National Health and Medical Research Council, 2013). in primary care necessitates a broad review of literature that includes
In Australia the Preventative Health Taskforce (Australian quantitative, qualitative, mixed methods studies and grey literature. As
Government and Preventive Health Taskforce, 2009) stress that pri- well as allowing exploration of literature from different theoretical
mary care prevention should be targeted at reducing the likelihood of frameworks, a scoping review method will identify if any systematic
developing obesity as the health consequences are cumulative and not reviews have already been undertaken and identify gaps in the litera-
always reversible. Reducing the likelihood of obesity through primary ture that may lead to future exploration (Arksey and O'Malley, 2005).
care health advice strategies may be more beneficial and cost effective The five stage framework identified by Arksey and O'Malley (2005)
than weight loss programmes. guided this study; identifying the research; identifying relevant studies;
study selection; charting the data; and, collating, summarising and re-
1.3. Rationale for research porting the data.
Once the research questions were developed (Stage 1) the re-
The World Health Organisation (2017) refers to health promotion as searchers identified the search terms for the study. The following
a process by which people are enabled to gain control and improve their electronic databases were searched: Emcare, Ovid, Embase, The
health. Improvements in lifestyle, through nutritional and physical Cochrane library, ProQuest family health, Health source (nursing aca-
activity health advice for overweight individuals, can prevent obesity demic), Joanna Briggs Institute EBP database, Medline, PubMed, Rural
(Booth and Nowson, 2010) and its associated comorbidities such as and remote, Proquest (nursing and allied health) and TRIP. The search
hypertension and Type 2 diabetes (Booth and Nowson, 2010; Dorsey terms ‘health advice’, ‘brief advice’, ‘health promotion’, ‘health pre-
and Songer, 2011). The adoption of health promotion strategies such as vention’, ‘health education’ and ‘obese’, ‘overweight’, BMI ‘weight
behavioural change and cognitive theory appear to be common in the management’, ‘weight maintenance’, and ‘doctor’, ‘general practi-
giving of health advice (Anderson, 2008; Brauer et al., 2015; Flocke tioner’, ‘GP’, ‘physician’, ‘nurs*’, ‘practice nurse’, and ‘primary care’,
et al., 2005; Grandes et al., 2009; Noël and Pugh, 2002; Sargent et al., ‘primary health care’ and ‘community health care’ were used. The terms
2012). However, before health advice can be initiated, it is important to ‘general practitioners' and ‘nurses' were also used instead of ‘health care
identify in a timely way those individuals that require it, underpinned professionals’ to keep the focus on the field of general practice rather
by best available evidence. than dietetics. ‘Physician’ as well as ‘general practitioner’ was used to
The aim of this scoping literature review is to examine and map capture work from an international perspective. Search parameters
when health advice is offered to overweight patients by general prac- outlined in the inclusion and exclusion criteria are detailed in Fig. 1.
titioners and nurses in primary care and to understand the nature of the Papers were excluded not based on assessment of study quality but on
advice provided. relevance to the research question. This was utilised to avoid

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K. Walsh et al. Preventive Medicine Reports 14 (2019) 100812

Fig. 1. Inclusion and exclusion criteria.

oversaturation of irrelevant literature. previous frameworks for the searching, selecting, extracting and
Stage three involved searching of bibliographies for any further charting of evidence. This enabled the identification of the relevant
articles. In order to manage the vast amount of references, Endnote was information for collation into a summary table (Table 1.).
utilised and Covidence was used to share the identified literature with Charting the information from the studies was the final stage. Levac
the second reviewer. A modified PRISMA flow chart (Fig. 2) was gen- et al. (2010) enhancements in addition to Arksey and O'Malley's (2005)
erated to show the way in which studies were selected. During the full framework were drawn upon to increase consistency and rigour. Three
text screening process, the date range for inclusion was changed to steps were undertaken: 1) analysing data, involving a descriptive nu-
2008–2018. The 10 articles generated prior to this did not correspond merical summary and a thematic content analysis; 2) reporting the
to the most recent obesity guidelines that were released by NICE results collated into a table (Table 1) to articulate the findings of the
(2006). As a scoping literature review is an iterative process (Arksey studies; 3) applying meaning involved a content analysis of the results
and O'Malley, 2005), it allows the flexibility to make this change. Two (Levac et al., 2010). Gaps in the literature were identified and re-
articles were also excluded during data extraction as they had no re- commendations for future research clearly stated.
levant data.
Stage four involved data extraction from the chosen studies using a
data extraction tool (Fig. 3). The data extraction tool was adapted from 2.1. Ethical considerations
The Joanna Briggs Institute (2015; Arksey and O'Malley, 2005). At this
point, it is possible to draw upon Peters et al. (2017) enhancement of This review was literature based therefore ethics approval was not
sought. Consideration was given to registering with PROSPERO, an

Fig. 2. Modified PRISMA flow chart.

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K. Walsh et al. Preventive Medicine Reports 14 (2019) 100812

Fig. 3. Data extraction tool.

international database of prospectively registered systematic reviews in loss conversation. They found that 42% of patients reported an interest
health and social care, however, it did not meet the criteria outline in weight loss but did not discuss it. Although, this study does have
https://www.crd.york.ac.uk/prospero/#aboutpage. notable limitations. The poster was not pre tested and it was not clear
whether the GP or the patient brought up weight.
3. Results van Dillen et al. (2014) carried out a study in the Netherlands to
examine the content of Dutch practice nurses' advice about weight,
The data base searches produced 484 journal articles. Duplicates nutrition and physical activity to overweight and obese patients. This
were removed and 248 citations were screened. The exclusion criteria study was a qualitative, observational study of 19 practice nurses, all
were applied to the title and abstract by two reviewers using Covidence, female. They found that practice nurses initiated conversations around
which excluded 213 articles. Thirty five (35) articles remained after full weight, nutrition and physical activity more than their patients. The
text screening. A decision was made to change the date range to results may however have been subject to a social desirability bias due
2008–2018 to capture more recent work. As a scoping review is con- to the recording of the conversations. Barte et al. (2012) carried out a
sidered to be an iterative process (Arksey and O'Malley, 2005), this was study relating to lifestyle interactions carried out by nurse practitioners
deemed appropriate. This excluded an additional 10 articles. During or a GP. They found that 80% of patients felt the nurse practitioner was
data extraction, 2 articles were found irrelevant to the inclusion and satisfactory (Barte et al., 2012).
exclusion criteria and were also removed. Twenty-three (23) articles While van Dillen et al. (2014) found that nurses brought weight up
were included in this scoping review. This included 2 mixed method more than patients, it is important to consider who is best placed to
studies, 14 qualitative studies, 5 quantitative studies, one systematic bring up weight with patients. ter Bogt et al. (2011) found that patients
review and one literature review. Content analysis identified 4 cate- receiving weight gain prevention strategies given by nurses did not lead
gories which are reported on below. to better results than by the GP and similarly, Noordman et al. (2012)
found that one primary care professional does not seem to be better
than another. However, Dutton et al. (2014) did find that female doc-
3.1. ‘When’ opportunities to give health advice occur tors were more likely to give health advice to lose weight than male
doctors and Sonntag et al. (2010) noted that female doctors had longer
The NHMRC (2013) refer to the ‘usual healthcare provider’, who is consults and more relating to weight. Interestingly, Yoong et al. (2014)
most often the GP or practice nurse, as most likely to be involved in found that the prevalence of overweight and obesity was reported to be
giving advice about a healthy lifestyle (p.14). It is suggested that their lower by the GP than the patient. 53% of the patients in their study
involvement would include assessing for BMI and health risks and re- identified as overweight or obese while the GP reported only 38%. It
cording them into the individual's records (Australian Government was also reported by Yoong et al. (2014) that 12% of obese were ca-
Department of Health and National Health and Medical Research tegorised as non - overweight. This finding highlights that there may be
Council (2013). This enables the doctor or nurse to easily identify those barriers faced by doctors and nurses in their identification of over-
in the overweight category, prompting the initiation of health advice. weight patients. While this may be due to lack of time, or poor edu-
Clune et al. (2010) carried out a qualitative study in the USA by cation (Bocquier et al., 2005; Rogers et al., 2012), it may also support
using questionnaires on 793 participants to examine the prevalence and McClinchy et al. (2013) who suggested that health promotion may not
predictors of health care professionals recommendations to lose weight. happen as health practitioners feel that it is not effective.
They found that 70% of participants met the weight loss criteria but This may explain why weight management is often considered to be
only 36% received advice to lose weight in the past year. However, the the role of the practice nurse. Shay et al. (2009) carried out a com-
study used self – reported data which may have led to recall bias. This prehensive review of articles and found that nurse practitioners were
notion of missed opportunities for health behaviour discussion is em- well placed to simply, safely and effectively integrate weight manage-
phasised in the work of Flocke et al. (2014) who examined the effec- ment strategies into their practice. Barte et al. (2012) carried out re-
tiveness of teachable moments to increase patients' recall of advice. This search to investigate lifestyle interactions by nurse practitioners. In
was a mixed method observational study of 811 patient visits to 28 their process evaluation of 11 general practices, with 457 patients, they
primary care clinicians and showed that there were missed opportu- found that > 80% reported satisfaction with health advice from the
nities in 61% of observed discussions. Another study which detected a nurse practitioner.
low frequency of education and referrals was Harris et al. (2012). They The BMI category in many of the studies often does not specify
carried out a qualitative survey of 698 participants and found a high whether the intervention takes place in the overweight or the obese
prevalence of behavioural risk factors in diet and physical activity. category. For example, Alexander et al. (2011), Barte et al. (2012), ter
72.6% of participants had behavioural risk factors relating to diet and Bogt et al. (2011) and Korhonen et al. (2014) used a similar grouping of
57.6% of participants had risk factors relating to physical activity. BMI over 25. Including the overweight category into the study is ben-
Despite the high figures, a low frequency of education was detected. eficial however, distinguishing between the BMI categories as being
Stephens et al. (2008) also noted a large number of missed opportu- overweight or obese would have provided a clearer understanding of
nities. They carried out a qualitative study to investigate the effects of a the representation of overweight and whether the advice resulted in a
simple visual prompts poster on occurrence of patient/physician weight

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 Table 1
Summary table.
NUMBER/author/ Location/design/sample Objective Theoretical framework When was health advice What health advice was given Findings Strengths/weaknesses
K. Walsh et al.

year given

1. Alexander et al. USA To see if physician weight loss Not explicit. In 63% of encounters of Nutrition: 9 subcategories. Combined advice in 34% Strengths:
(2011) Mixed method advice results in a change to Social cognitive theory/ either overweight or Physical activity: 6 Physical activity only in 13% Not self- selected and
461 patients patient dietary intake, physical motivational interviewing obese, BMI 25 > . subcategories. Nutrition only in 8% motivated.
40 physicians activity and weight. Did not specify BMI Specific Weight loss advice: 3 Weight loss only in 3% Large ethnically diverse
category (Overweight or categories. Patients who received combined sample.
obese) advice lost more weight than Weaknesses:
patients who received no advice Self- report for
but not statistically significant Not generalizable to
p = 0.08. young, low income.
2. Barte et al. Netherlands To investigate lifestyle interactions Groningen Overweight and BMI 25 > Based on national and > 80% satisfaction that healthy Weakness: Self report,
(2012) Process evaluation. by nurse practitioners compared Lifestyle (GOAL) international guidelines. eating and physical activity was relies on patient recall.
11 General practices. with general practitioners Intervention. useful by the NP. The intervention was not
implemented as designed.
3. Brauer et al. Canada To assess patient perceptions of Not explicit. Not discussed. Verbal advice and pamphlets Overall rate of diet counselling Weakness:
(2012) Qualitative2184 surveys preventive lifestyle counselling in were the most common. Verbal 37%, exercise counselling 24%. Self -report could lead to
sent to 3 Ontario family Primary care practice. (Shortly advice 61% initially and 78% Low rates of preventive bias.
health networks. after dieticians joined the family 1 year later. counselling
health network and 1 year later). Use of pamphlets 34% and 18%
1 year later.
Content of advice not reported.
4. Clune et al., USA To examine the prevalence and Not explicit. In those ‘overweight Not reported 70% of participants met the Weakness:
2010 Qualitative,793 men predictors of health care with risks’ 19.8% weight loss criteria but only Self-report may have led
and women over 60 professionals recommendations to In those ‘obese with 36% received advice to lose to recall bias
lose weight. risks’ 52% weight in the past year.

5
5. Dutton et al. USA To examine patient characteristics, Not explicit. Higher BMI was Not reported. A greater number of medical Weaknesses:
(2014) Cross-sectional survey physician characteristics and associated with more conditions was related to more Self-report may have led
with 143 respondents characteristics of the physician/ frequent weight loss frequent weight loss to recall bias.
patient relationship associated counselling, p < 0.001. counselling, p < 0.05. Homogeneous- difficult to
with weight loss counselling and Female doctors were more likely compare race and sex.
recommendations provided by to give weight loss advice. Modest sample size.
physicians. p < 0.03.
6. Eley and Eley Rural QLD, Australia To determine whether rural GP's Pope et al. (2000) 5 stage Not reported. 16 GP practices reported 16 GP practices cited motivation Weaknesses:
(2009) Qualitative survey use physical activity as a weight framework referring to gyms or fitness and commitment, lack of local Pilot study.
40 GP practices selected loss strategy and if so, how? classes facilities and lack of footpaths as Small sample size.
27 responded. 6 GP practices reported referring barriers to physical activity Did not state when they
to QLD health exercise (relating to rural areas) give advice.
physiologists and physio. Did not state what their
8 GP surgeries reported using advice was.
life scripts while 3 stated having
never heard of them, 3 noted
occasionally using them and 3
considered them a ‘gimmick’
‘not suitable’ and ‘ineffective’
7. Flocke et al. USA To examine the effectiveness of Health behaviour change. BMI 25 and over with Not stated. 86% had at least one Weaknesses:
(2014) Mixed method teachable moments to increase the presence of a chronic opportunity for discussion. No positive association
observational study of patients' recall of advice, condition. 45% had a health behaviour between TM and BMI
811 patient visits to 28 motivation to modify behaviour, BMI 30 and over with discussion. change at 6 weeks- too
primary care clinicians and behaviour change. under consumption of Missed opportunities 61% short
fruit and veg Audio recorder-bias
8. Halbert et al. USA To examine the receipt of provider Not explicit. 59% of participants Not stated Women were more likely than Self –reported may have
(2017) Qualitative advice to lose weight among advised to lose weight. men to be advised to lose led to patient recall bias.
observational study, primary care patients who were 41% had not received weight. Cross sectional design led
overweight and obese. advice. Obese were more likely to report to inability to determine
(continued on next page)
Preventive Medicine Reports 14 (2019) 100812
 Table 1 (continued)

NUMBER/author/ Location/design/sample Objective Theoretical framework When was health advice What health advice was given Findings Strengths/weaknesses
year given
K. Walsh et al.

cross sectional study. 40% overweight being asked to lose weight than causality of receipt of
282 participants participants had been overweight. provider advice.
advised to lose or Health advice given was
maintain weight. not reported.
9. Harris et al. Australia To explore whether education and (Prochaska and Di Those given dietary Those with higher BMI recorded High prevalence of behavioural Self –reported, potential
(2012) Qualitative survey. referral by GP's to patients with Clemente, 1986) Stages of advice had mean BMI of were more likely to receive a risk factors in diet and physical recall bias.
698 participants smoking, nutrition, alcohol, behaviour change. 30.01, those not, mean referral for dietary or physical activity. Diet 72.6% physical Practices were volunteers
physical activity and weight BMI 27.76 activity than those with lower activity 57.6%. that expressed an interest
(SNAPW) behavioural risk factors Those given physical BMI score. Mean BMI 28.4. which may have
is tailored to patients risk and activity advice mean Low frequency of education and influenced the likelihood
readiness to change. BMI 30.23,those not referral of patients with SNAPW of them addressing it.
mean BMI 27.52 in general practice.
10. Kable et al. Australia Qualitative To report perceptions, practices Not explicit. 28% measure height and Quality of weight loss advice 74% of nurses provided dietary Weaknesses:
(2015) cross sectional survey. and knowledge of nurses about weight was not attainable. advice. Participation was
79 participants, providing healthy lifestyle advice 18% measure waist 72% had no or low level 81% of nurses provided physical voluntary which may
for patients who may be 65% were aware that knowledge activity advice. suggest an interest.
overweight or obese and compare overweight was defined 44% recommended increasing Most nurses reported not Low response rate noted,
responses from demographic as BMI 25 and over physical activity. receiving education which may have produced
regions. Only half of the participants a non- response rate bias.
were confident to raise issue Nurses were not all in
primary care
11. Korhonen Finland To identify overweight and obese Not explicit. BMI 25 and over Aim to reduce weight by 5% by By targeted screening it is Weaknesses:
et al. (2014) Longitudinal cohort with increased cardiovascular risk Waist circumference reducing saturated fat and possible to find overweight and There was no comparison
study. in the community and provide 80 cm and over in increasing physical activity to at obese people at increased group.
2752 at risk subjects. with lifestyle counselling that is females or 94 cm and least 30 mins per day or 4 h per cardiovascular risk, to induce 3 year follow up was 42%

6
possible to implement in real life. over in males. week. clinically meaningful, long
–term, weight loss or
stabilisation in primary care.
12. Noordman Netherlands To review literature on relative Reference to Prochaska and No difference shown Behavioural counselling, One primary care professional Strengths:
et al. (2012) Systematic review effectiveness of face to face Di Clemente's trans between GP's and nurses' motivational interviewing, does not seem better equipped High quality strategic
RCT, 18 yrs > , lifestyle communication related behaviour theoretical model of however, few studies education and advice are most that another to provide face to review
communication, PCT change techniques provided in behavioural change and include both so caution frequently evaluated as effective face related BCT's. Included studies with
primary care by either physicians Bandura's social cognitive must be exercised. face to face communication rigorous design
or nurse to intervene on patients' theory. related BCT's Weaknesses:
lifestyle behaviour. Publication bias.
Non- English excluded.
13. Pollak et al. USA To analyse time spent on the topic Epstein et al. (2005) patient Nutritional advice was Not stated. Mean time of 3.3 min was spent Weaknesses:
(2011) Qualitative40 primary of weight and whether centred communication. given on 78% addressing the topic. Study may not be
care physicians, 461 motivational interviewing was Motivational interviewing. Physical activity advice Obese patients spent longer generalizable to young
encounter used. was given on 82% talking about weight than people with lower
BMI/weight was taken overweight. incomes.
on 72%
14. Robertson Australia QLD To ascertain the extent to which Not explicit. GP's recommended 81% 75% were advised to walk Obese were most likely to be Weaknesses:
et al. (2011) Qualitative1261 general practitioners in Health promotion. 24.7% was in the last 13% swimming/aqua aerobics/ recommended to do more Self -report may lead to
participants Queensland recommend physical year. hydrotherapy/low impact exercise 34%, followed by recall and social
activity to their patients, the types 40% of overweight exercise overweight 15%, acceptable desirability bias.
of patients they target, types of participants were 13% to use gym/weights or weight 7%, and underweight No description of BMI
activity they suggest and how advised to exercise aerobics. 4%. given.
patients respond to the more.
recommendations. 17% had heart problems.
15% had diabetes,
asthma or osteoporosis
15. Schauer et al. USA Qualitative 30 P.C. To use qualitative methods to Not explicit. Addressed with all, Specific diets, walking common, Overwhelming majority have no Weaknesses:
(2014) physicians, nurses, explore how clinicians approach rapport first, chronic increase activity external resources or Self -report may lead to
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Preventive Medicine Reports 14 (2019) 100812
 Table 1 (continued)

NUMBER/author/ Location/design/sample Objective Theoretical framework When was health advice What health advice was given Findings Strengths/weaknesses
year given
K. Walsh et al.

assistants from weight counselling, including who, consults, unwritten Some develop their own or use behavioural treatments, e.g. recall bias.
4 multi clinic health how, what, and what referrals. protocol when to address existing brochures or handouts. dietician, classes, programmes. Not generalizable to the
centres it, when doing vitals Some told to google weight loss whole population.
apps.
16. Shay et al. USA Comprehensive To provide a practical approach to Not explicit. It should be addressed Advice should be: Nurse practitioners can easily
(2009) review of articles managing overweight and obese when BMI is calculated Calorie intake and goal weight, integrate simple, safe, and
adult patients based on data from and a diagnosis of educate, follow up, weight effective weight management
research and recommendations overweight or obese is maintenance. strategies into their practice.
from established guidelines. given.
17. Shuval et al. USA To examine the reliability and 5 A's framework During routine visits. No specific advice noted. Sedentary behaviour Weaknesses:
(2014) Pilot Cross sectional validity of brief sedentary Most participants were 10% reported sedentary counselling practices are No specific advice noted,
study. assessment tool for primary care. overweight with a mean behaviour counselling in the last infrequent in primary care Self – report, limited
157 patients, BMI of 27. year. clinics. sample size, one primary
53% received physical activity care clinic.
counselling
45% advised to modify physical
activity time.
None received a written plan
18. Stephens et al. USA To investigate the effects of a 5 A's framework When patients brought Not stated. 42% reported interest in weight Weaknesses:
(2008) Qualitative. Survey of simple visual prompts poster on weight up or when GP loss but did not discuss it with No demographics taken.
283 participants pre occurrence of patient/physician brought weight up. Not the physician. Poster was not pretested.
intervention, weight loss conversation. very clear. Visual prompt poster did not Not documented who
386 in post intervention. increase proportion of patients initiated the discussion.
reporting they wanted to lose
weight.

7
19. Sonntag et al. Germany Cross sectional To analyse GP encounters with Not explicit. Not clear. During Not stated. 78% of dialogues were between Weaknesses:
(2010) study with 12 GP overweight and obese patients. To Behavioural change theory. biennial checks of over 0 and 6.76 min. BMI - self reported may
practices. test whether patients with a BMI 35 year olds. 70% of dialogues had physical have been influenced by
30 or over had longer activity brought up. social desirability bias.
consultations relating to lifestyle, Female GPs had longer consults GP's volunteered- may
nutrition and physical activity and more consults relating to suggest they were more
than those with a BMI under 30. weight/nutrition than male GP's motivated
20. ter Bogt et al. Netherlands. To compare structured lifestyle Not explicit. BMI 25 or over with a co Not stated. Preventing weight gain by Nurse Strengths:
(2011) Quantitative. counselling by nurse practitioners morbidity. practitioners did not lead to Large population, equal
Randomized controlled with usual care from GP. To see if better results than GP's. male and female
trial. results at 1 year were sustained at participants, low dropout
11 general practitioners, 3 years. rate.
457 participants, Weaknesses: Hawthorne
effect, participants had to
be informed of the study
21. van Dillen Netherlands Qualitative. To examine the content of Dutch Not explicit. PN initiated/PT To lose weight. Reduce fat, salt, Majority of advice based on Weaknesses:
et al. (2014) Observational study. 19 practice nurses' advices about initiated. sugar, alcohol, increase fruit. guidelines, type II diabetes in No ethics approval
practice nurses weight, nutrition and physical Weight 118/39 1 in 10 included possibility of particular. Recording may have
activity to overweight and obese Nutrition 161/78 dietician Advice based on GP standards resulted in bias.
patients. Physical activity 135/66 Be more active- walking, for a specific illness.
cycling. BMI was calculated in 9%
Often not tailored
22. Waring et al. USA To examine overweight and Not explicit: The higher the BMI the Behavioural interventions. Documentation of OW/obesity Weaknesses:
(2009) Quantitative obesity management in primary Behavioural change theory more likely to have To lose weight, was associated with higher odds Not generalizable- mostly
care in relation to Body Mass weight status and Physical activity, diet, of advice to lose weight among white non-Hispanic
Index, documentation of weight intervention referral to nutritional OW compared with mild/ Unclear who initiated the
status, and comorbidities documented counselling moderate/severe obesity. conversations.
Advice was prevalent in > 50%
(continued on next page)
Preventive Medicine Reports 14 (2019) 100812
K. Walsh et al. Preventive Medicine Reports 14 (2019) 100812

change to that group. Waring et al. (2009) also found that general
practitioners may document that patients are overweight when they are
Strengths/weaknesses

actually obese. Having more accurate and specific data on the BMI
category for lifestyle interactions may lessen the blurring of the
boundaries between overweight and obese and may assist in more
tailored advice for patients.
Dutton et al. (2014) found that a higher BMI was associated with
more frequent weight loss counselling, (p < 0.001). BMI was also
type II diabetes had higher odds

found to be a significant factor in weight loss recommendations

12% of obese were categorised

Males without hypertension or
of patients with a documented

lower than the patient report-

(p < 0.04). Similarly, Waring et al. (2009) found that the higher the
overweight and obesity was
GP reported prevalence of

BMI, the more likely patients were to have their weight status and in-
of not being identified.

tervention documented. However, van Dillen et al. (2014) found that

mod/severe obesity.

as none overweight

BMI was calculated in only 9% of patients. Without calculating a BMI, a

barrier is formed, disengaging the nurse from providing appropriate
38% v. 53%

health advice to those who require it.

Findings

3.2. Barriers to giving health advice

Schauer et al. (2014) carried out a qualitative study to explore how

What health advice was given

clinicians approach weight counselling. Some describe unwritten pro-

tocols of when to address it. For example, they may address it with
those they have already built a rapport with, they won't address it with
a new patient so as to not ‘get off on the wrong foot’ and, ‘if it's not too
Not discussed.

offensive’, they will bring it up. This study highlights that some of the
barriers discussed in other literature such as lack of time and training
(Bocquier et al., 2005; Rogers et al., 2012) continue to be an issue in
practice. Having time to build a rapport with patients and being given
appropriate training to address the issue in a non-offensive manner may
When was health advice

increase the likelihood of it being addressed.

Many studies only included overweight participants if there was a
Not discussed.

comorbidity present. The NHMRA (2013) suggest screening and

managing comorbidities in their standard care for those in the over-
weight BMI range. However, it does not suggest that advice only be
given

given to those with a comorbidity. ter Bogt et al. (2011), Clune et al.
(2010), Flocke et al. (2014) and Korhonen et al. (2014) only included
the overweight category in their study if the participants had a co-
Theoretical framework

morbidity. This is interesting, as health advice would be suited to pa-

tients in the overweight category regardless of comorbidity and having
the advice sooner may lead to less people developing a comorbidity.
Not explicit.

Dutton et al. (2014) found that having more medical conditions

equalled more frequent counselling. This may relate to Schauer et al.
(2014) who found that clinicians were more inclined to bring up weight
while in a consult for a chronic condition as opposed to an acute con-
dition.
overweight and obese patients.

The literature reviewed also demonstrated an under representation

of people in the age category of 18–40 years. An Australian study by
Australian GP's recognise
To determine extent that

Harris et al. (2012) carried out a qualitative survey of 698 participants

aged between 40 and 55 years with hyperlipidaemia or hypertension or
aged 56–64 years. Those not given dietary advice had a mean BMI of
27.76, the overweight category. Those not given physical activity ad-
Objective

vice had a mean BMI of 27.52, the overweight category. Clune et al.
(2010) also carried out a study in those over 60 years and found low
rates of health advice given. As many studies require their overweight
Location/design/sample

participants to have a comorbidity, this may explain the age category of

sectional study. 1111

over 40 years as there may be more prevalence in that age category. The
Qualitative. Cross

presence of the chronic disease may also mean that they present more
to the doctor or nurse. People under 40 may also be less likely to go to
Australia

the GP in general as they may have fewer health issues.

patients

3.3. Nature of the health advice provided

Table 1 (continued)

NUMBER/author/

23. Yoong et al.

3.3.1. Nutrition
Alexander et al. (2011) found that health advice relating to nutri-
(2014)

tion was given to only 8% of patients in their study. Brauer et al. (2012)
year

highlight that verbal advice and pamphlets were the most common in
diet and exercise counselling. The exact content of the advice was not

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K. Walsh et al. Preventive Medicine Reports 14 (2019) 100812

reported. The use of pamphlets in health advice was also noted by inclusion and exclusion criteria.
Schauer et al. (2014). They found that some clinicians develop their While every attempt was made to ensure that this study was of high
own or use existing brochures or handouts. The reliability of pamphlets quality some limitations apply including the strict 10 year inclusion
or handouts could be questioned as they may be out of date or disease criteria and the use of English language only research.
specific. The array of nutritional information that was given as health
advice in Schauer et al. (2014) emphasises the inconsistency around 5. Conclusion
this advice. Some patients were advised to google weight loss apps.
Given the oversaturation of weight loss applications and uncertainty of The literature reviewed in this study has highlighted that there
their validity, reliability and use of evidence based practice guidelines, continues to be poor documentation of BMI by doctors and nurses in
this advice may prove to be of poor quality. It is interesting to note that primary care. Health advice is more likely to be given when BMI in-
Schauer et al. (2014) found that the overwhelming majority of primary creases and can be of poor quality due to educational barriers and
health care facilities have no external resources or behavioural treat- availability of resources. Primary care doctors and nurses are well po-
ments, for example dietician, classes and programmes. Most existing sitioned to give weight related health advice. Female practitioners are
ones are for diabetes (Schauer et al., 2014). Kable et al. (2015) state more likely to raise the topic of BMI and weight control than male
that 72% of the nurses in their study had no or low level knowledge practitioners. Very few studies have documented the exact health ad-
about best practice dietary management for overweight. This empha- vice that was given. Barriers to giving health advice to overweight
sises the training barriers associated with health advice as discussed by patients in primary care continue to be problematic and need to be
Rogers et al. (2012) and Schauer et al. (2014). It also highlights that acted on to improve population health.
education in the form of a toolkit for doctors and nurses, similar to
those in other chronic diseases may be useful (Glenister et al., 2017). 6. Future recommendations

3.3.2. Physical activity Future recommendations involve the potential of a study which is:
Physical activity advice is one part of the multicomponent nature of
health advice for weight management. Alexander et al. (2011) found • Longitudinal
that physical activity advice occurred in 13% of primary care en- • Has primary care nurses as the focus
counters in their study. There was no reference made to whether the • Records when BMI is taken and documented
advice given derived from evidence based practice or local and national • Details what health advice is given to patients that are overweight
guidelines. This may have influenced the effectiveness of the advice • Includes participants from the age range of 18 +
given. Eley and Eley (2009) found that 16 GP practices reported re- • Includes participants from all social demographics
ferring to gyms or fitness classes and 6 GP practices reported referring
to exercise physiologists and physiotherapists. These data could be used to generate a tool kit that could be dis-
Kable et al. (2015) conducted a study to report the perceptions, tributed to primary care nurses that provides standardised education for
practices and knowledge of nurses providing healthy lifestyle advice for giving brief health advice to overweight patients. This gives clear in-
patients who may be overweight or obese. The quality of the weight loss structions that link current overweight and obesity guidelines into
advice was not attainable. This study reports that 44% of nurses re- practice by offering quality, evidence based, brief, nutrition and ex-
commended increasing physical activity and 81% of nurses provided ercise advice. The tool kit could include quality assessed posters for
physical activity advice. However, most nurses reported not receiving waiting rooms, strategies for screening patient loads, in order to be
any education in relation to this. It is important to point out that this proactive in offering preventive advice, and assistance in in-
study included nurses from other areas as well as primary care. This dividualising advice while keeping it brief and simple.
may have influenced the educational level of the nurses as obesity
guidelines have targeted primary care workers as those in the best Formatting and funding
position to provide health advice for weight management. Although, it
could be argued that all health care professionals have a duty of care to This research did not receive any specific grant from funding
educate their overweight patients with evidence based health advice. agencies in the public, commercial, or not-for-profit sectors.
Korhonen et al. (2014) targeted screening to overweight and obese
giving specific health advice relating to physical activity. This advice Conflicts of interest
was to increase physical activity to at least 30 min per day or 4 h per
week. While the study does give detail of the advice given, it does not None.
state the evidence base. Robertson et al. (2011) found that 75% of their
study participants were advised to walk. Similarly, Schauer et al. (2014) Acknowledgments
and van Dillen et al. (2014) also reported that very general physical
activity recommendations such as walking were used. van Dillen et al. We would like to thank the University of South Australia library
(2014) emphasise that the majority of advice was based on guidelines, staff for continuous support with this project.
type 2 diabetes in particular, or on GP standards for specific illnesses.
They report that tailored education was seldom provided. Again, the References
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