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Population estimates from 2008 revealed that more than two
thirds of the US adults were either overweight or obese (1).
Such trends are alarming, as obesity is associated with well-
established risk of comorbidity and mortality (2,3). Research
has revealed that even modest weight loss (5–10% decrease
of initial body weight) is favorable, as it is associated with
improvement in blood pressure, lipid profile, and glycemic
control (4–6); thus, the reduction of excess weight is a target
for study and intervention.
Still, despite the documented benefits of weight loss for over-
weight and obese individuals, the prevalence of weight loss
effort among overweight and obese individuals is relatively low.
Data from the National Health Interview Survey indicate that
fewer than half of overweight men and women and less than
two thirds of obese men and women were attempting weight
loss in 1998 (7). Research suggests that physician involvement
in weight loss is associated with increased intention to lose
weight, commencement of weight loss, and improved weight
loss maintenance in overweight and obese patients (8–10).
However, physician care of obesity is infrequent and incon-
sistent (11–13), and physicians are selective when diagnosing
overweight and prescribing weight loss (11–14). Furthermore,
physicians are generally unfamiliar with the thresholds for
obesity and abdominal obesity that indicate increased cardio-
metabolic risk (15); thus, although physicians recognize that
counseling on weight loss is an essential component of their
clinical practice (16), overweight and obese individuals may go
Some research suggests that counseling for weight manage-
ment delivered by health professionals may be decreasing over
time (17–19). However, the secular trends of physician diag-
nosis of overweight and obesity and physician-directed weight
loss during the past 20 years, using nationally representative
data and objectively measured height and weight, have yet
to be examined at length. Furthermore, little is known about
the concurrent secular trends of self-care of overweight and
obesity among adults in the United States.
Thus, the objectives of the following analysis were to evaluate
the secular trends in the care of overweight (diagnosed over-
weight and directed weight loss), to investigate the association
between obesity and care of overweight in primary care over
time, and by comorbidity status, and to examine the associa-
tion between obesity and self-care of overweight over time.
Secular Trends in the Diagnosis and Treatment
of Obesity Among US Adults in the Primary
Erika A. Yates1, Alison K. Macpherson1 and Jennifer L. Kuk1
Excess weight afflicts the majority of the US adult population. Research suggests that the role of primary care
physicians in reducing overweight and obesity is essential; moreover, little is known about self-care of obesity. This
report assessed the secular trends in the care of overweight and investigated the secular association between obesity
with care of overweight in primary care and self-care of overweight. Cross-sectional evaluation of the National Health
and Nutrition Examination Survey (NHANES) III (1988–1994) and the Continuous NHANES (1999–2008) was employed;
the total sample comprised 31,039 nonpregnant adults aged 20–90 years. The relationship between diagnosed
overweight, and directed weight loss with time and obesity was assessed. Despite the combined secular increase
in the prevalence of overweight and obesity (BMI >25.0 kg/m2) between 1994 and 2008 (56.1–69.1%), there was no
secular change in the odds of being diagnosed overweight by a physician when adjusted for covariates; however,
overweight and obese individuals were 40 and 42% less likely to self-diagnose as overweight, and 34 and 41% less
likely to self-direct weight loss in 2008 compared to 1994, respectively. Physicians were also significantly less likely to
direct weight loss for overweight and obese adults with weight-related comorbidities across time (P < 0.05). Thus, the
surveillance of secular trends reveals that the likelihood of physician- and self-care of overweight decreased between
1994 and 2008 and further highlights the deficiencies in the management of excess weight.
Obesity (2011) doi:10.1038/oby.2011.271
1School of Kinesiology & Health Science, York University, Toronto, Ontario, Canada. Correspondence: Jennifer L. Kuk (email@example.com)
Received 16 May 2011; accepted 25 July 2011; advance online publication 00 Month 2011. doi:10.1038/oby.2011.271
Methods and Procedures
The National Health and Nutrition Examination Survey (NHANES)
is a series of nationally representative surveys focusing on varying
health issues, to produce national health statistics. The third NHANES
(1988–1994) comprised two phases, each using a complex, multistage,
probability sampling method to select a cross-sectional sample rep-
resentative of the total noninstitutionalized civilian population in the
United States. Starting in 1999, NHANES became a continuous survey
that released data on a biannual basis.
For data obtained at the mobile examination center, medical techni-
cians undergo extensive training prior to and during data collection; all
anthropometrics were measured during the physical examination and
have been collected using similar protocol since 1988 (20,21). BMI was
computed as weight in kilograms divided by height in meters squared.
Waist circumference was measured to the nearest 0.1 cm at the midaxil-
lary line of the body. Standard BMI categories for normal weight, over-
weight, and obese, and sex-specific cutoffs for waist circumference (men:
94 and 102 cm; women: 80 and 88 cm) were utilized in the analyses.
Physician- and self-diagnosis of overweight and physician- and self-
directed weight loss were assessed using data collected by questionnaire;
questionnaire data assessing the care of obesity were not available in
NHANES; thus, the assessment of diagnosis and treatment of over-
weight were utilized in this analysis to represent that of excess weight as
a whole. Respondents were asked if ever told by a doctor that they were
overweight, if ever told by a doctor to lose weight for hypertension or
hypercholesterolemia, if they considered themselves overweight, and if
they had attempted weight loss during the previous 12 months. To evalu-
ate secular trends and associations, the survey year was used to represent
time. The combined sample (composed of NHANES III and NHANES
continuous surveys) included 103,577 adults (total screened sample);
after exclusions, the combined sample comprised 31,039 nonpregnant
adults, 20–90 years of age. NHANES participants completed written
informed consent, and the NHANES institutional review board/NCHS
research ethics review board approved study protocol.
For the purpose of this analysis, individuals with missing data for age,
sex, BMI, and those with a BMI <18.5 kg/m2 were excluded. The unad-
justed, weighted secular prevalence of overweight and obesity, diagnosed
overweight and directed weight loss, was assessed using the survey fre-
quency procedure; changes over time in these measures were examined
using trend analysis by logistic regression. Trend analysis using multiple
logistic regression analysis was conducted to determine secular changes
in the association between care of overweight with obesity and time.
Separate analyses to assess the interaction between obesity and time
(BMI × time; WC × time) were also modeled. Where the interactions
were statistically significant (P < 0.05), the models were stratified by BMI
and WC categories, respectively. All analyses were performed using SAS
statistical software (version 9.2) (SAS Institute, Cary, NC).
All multivariate analyses were adjusted for age, sex, ethnicity, education
level, and smoking status. Analyses of physician-diagnosed overweight,
physician-directed weight loss for hypertension, and physician-directed
weight loss for hypercholesterolemia were further adjusted for health
insurance; the analysis of physician-directed weight loss for hyperten-
sion was restricted to those taking antihypertensive medication, and the
analysis of physician-directed weight loss for hypercholesterolemia was
restricted to those taking lipid-lowering medication.
Weighted sample characteristics are reported in Table 1.
secular prevalence of diagnosed overweight
and directed weight loss
Nearly 70% of respondents were classified as overweight or
obese in 2008, a significant increase since 1994 (Figure 1);
similar increases in abdominal obesity were observed (results
not presented). Though the prevalence of both reported
table 1 Weighted sample characteristics, across survey years
19942000 2002 20042006 2008
Age (years)45.2 (0.5)45.6 (0.4)45.4 (0.5)46.8 (0.5)47.1 (0.8) 47.0 (0.4)
Sex (%): men48.550.550.050.250.049.2
Insurance (%): yes85.181.282.582.080.9 80.6
Less than high school184.108.40.206.86.6 6.8
More than high school41.149.355.854.557.454.4
Smoking status (%)
BMI (%): ≥25.0 kg/m2
Diagnosed hypertension (%)24.224.825.430.830.630.8
Diagnosed hypercholesterolemia (%)37.235.941.542.7
Presented as mean (s.e.m.) or frequency.
physician- and self-diagnosed overweight increased across
time, the prevalence of self-diagnosed overweight was sub-
stantially higher than physician diagnosis for each survey year
(Figure 1). Significantly more respondents with hypercholeste-
rolemia, but not hypertension, reported being directed to lose
weight in 2008 than in 1994 (Figure 1). Contrarily, respond-
ents reported directing their own weight loss less often in 2008
than in 1994 (Figure 1).
association between diagnosed overweight
and directed weight loss with time
The interaction between time (survey year) and BMI was signif-
icant for self-diagnosed overweight (P < 0.05) and self-directed
weight loss (P < 0.0001), but not for physician-diagnosed over-
weight or physician-directed weight loss for hypertension and
hypercholesterolemia (P > 0.05). Accordingly, we elected to
stratify the models by BMI category (overweight, obese) to
further evaluate the interaction between time and BMI.
The secular evaluation of care of obesity herein is relative to
1994 (the earliest year of measurement), with the exception
of physician-diagnosed overweight, where 2000 is the earliest
year of measurement. There was no main effect of time (secular
effect) on physician-diagnosed overweight among overweight
individuals (P = 0.093); however, physicians were less likely to
diagnose obese individuals as overweight in 2002 (odds ratio
(OR): 0.83 (95% confidence interval: 0.69, 0.99)) and 2004 (OR:
0.77 (95% confidence interval: 0.65, 0.92)) than in 2000, but not
in 2006 (OR: 0.86 (95% confidence interval: 0.72, 1.02)) or 2008
(OR: 0.86 (95% confidence interval: 0.73, 1.01); Table 2).
The likelihood of self-diagnosing as overweight was signifi-
cantly lower in years successive to 1994. In 2008, overweight
individuals were 42% less likely to self-diagnose as over-
weight compared to overweight individuals in 1994 (Table 2).
However, the association between time and self-diagnosed
overweight in obese individuals was much less consistent:
obese individuals were 22, 26, and 40% less likely to self-diag-
nose as overweight in 2000, 2004, and 2008, respectively; but
Ptrend < 0.0001
Ptrend < 0.0001
Ptrend < 0.0001
1996 19982000 2002 200420062008
Ptrend = 0.0001
Ptrend = 0.8009
Ptrend < 0.0001
Ptrend < 0.0001
1996 19982000200220042006 2008
Figure 1 Weighted secular prevalence of overweight and obesity,
and care of obesity measures, among US adults between 1994 and
2008. (a) Physician-diagnosed overweight (PHYSdiagOW) and self-
diagnosed overweight (SELFdiagOW); (b) physician-directed weight
loss for hypertension (PHYSwlHBP), physician-directed weight loss
for hypercholesterolemia (PHYSwlHBC), and self-directed weight loss
(SELFwl); the weighted prevalence of PHYSwlHBP and PHYSwlHBC
applies to individuals with diagnosed hypertension and diagnosed
table 2 unweighted adjusted odds of being diagnosed overweight, over time by BMI category
Odds ratioOdds ratio
Odds ratio95% C.I. 0.41.01.6Odds ratio95% C.I. 0.41.01.6
20020.70 0.610.800.880.69 1.11
Physician-diagnosed overweight: the reference group is the respective BMI category in 2000, adjusted for age, sex, ethnicity, education, smoking status, BMI, and health
insurance; overweight (N = 7,903); obese (N = 7,497). Self-diagnosed overweight: the reference group is the respective BMI category in 1994, adjusted for age, sex,
ethnicity, education, smoking status, and BMI; overweight (N = 11,148); obese (N = 9,804).
no less likely to self-diagnose as overweight in 2002 (OR: 0.88
(95% confidence interval: 0.69, 1.11)) or 2006 (OR: 0.90 (95%
confidence interval: 0.72, 1.13)) than in 1994.
Overweight individuals with hypertension were significantly
less likely to be directed to lose weight by their physician in
2000 (OR: 0.68 (95% confidence interval: 0.53, 0.87)) and 2002
(OR: 0.63 (95% confidence interval: 0.49, 0.81)), but not in
2004, compared to 1994 (Table 3). Similarly, obese individuals
were 31–40% less likely to be told to lose weight for hyper-
tension between 2000 and 2004, relative to 1994. Overweight
individuals with hypercholesterolemia were 17–29% less likely
to be told by a physician to lose weight between 2000 and 2006
relative to 1994; however, there was no difference in 2004 or
2008 (Table 3).
Both overweight and obese individuals were consistently
less likely to direct their own weight loss over time (Table 3).
Notably, overweight and obese individuals were 34 and 41%
less likely, respectively, to self-direct weight loss in 2008 com-
pared to those in the corresponding BMI category in 1994.
Results for analysis with waist circumference are not shown;
however, it should be noted that they were similar to the results
of analysis using BMI.
Despite the overall secular increase in the prevalence of
overweight and obesity, the likelihood of physician-diagnosed
overweight went unchanged between 2000 and 2008, and
both overweight and obese individuals were less likely to
self-diagnose overweight across time. Similarly, overweight
and obese individuals were less likely to be physician- or self-
directed to lose weight across time.
Evidence suggests that the threshold for self-classification as
overweight has increased during the past two decades (22–24).
That, in this analysis, overweight respondents were 29–42%
less likely to self-diagnose as overweight in years successive to
1994 may reflect the shifting threshold for self-perception of
overweight across time. Evidence also reveals that self-reported
ideal body weight has increased over time (25,26). As those
who are satisfied with body weight are less likely to perceive
a weight problem (26), it is thus plausible that the decreasing
likelihood of self-diagnosed overweight over time observed in
this analysis is in part a product of these trends. Furthermore,
research suggests that obesity in one’s social network may
influence acceptance of increased weight and may encourage
poor eating and exercise behavior (27). In this analysis, we
table 3 unweighted adjusted odds of physician-directed weight loss and self-directed weight loss, over time by BMI category
Odds ratioOdds ratio
Odds ratio95% C.I. 0.41.01.6 Odds ratio95% C.I. 0.41.01.6
Physician-directed weight loss for hypertension
Physician-directed weight loss for hypercholesterolemia
20000.760.580.98 0.940.67 1.33
20020.71 0.540.910.710.51 0.98
2004 0.830.661.061.00 0.741.36
Self-directed weight loss
2002 0.59 0.510.680.590.510.69
Physician-directed weight loss for hypertension: the reference group is the respective BMI category in 1994, adjusted for age, sex, ethnicity, education, smoking status,
BMI, health insurance, and antihypertensive medication; overweight (N = 2,394); obese (N = 2,717). Physician-directed weight loss for hypercholesterolemia: the refer-
ence group is the respective BMI category in 1994, adjusted for age, sex, ethnicity, education, smoking status, BMI, health insurance, and lipid-lowering medication;
overweight (N = 3,128); obese (N = 3,052). Self-directed weight loss: the reference group is the respective BMI category in 1994, adjusted for age, sex, ethnicity, educa-
tion, smoking status, and BMI; overweight (N = 10,287); obese (N = 8,585).
demonstrated that both overweight and obese respondents
were considerably less likely to self-initiate their own weight
loss in 2008 relative to 1994. Given the now widespread
commonality of overweight and obesity, it is possible that these
factors may ultimately translate into a smaller proportion of
overweight individuals interested in losing weight over time.
In this study, there was no change in the adjusted odds of
physician-diagnosed overweight among overweight individu-
als; though, obese respondents were less likely to be physician-
diagnosed as overweight in 2002 and 2004, compared to 1994—a
trend that is consistent with findings reported previously (17,19).
This result is alarming considering that simple and inexpensive
anthropometric measures for identifying overweight and evi-
dence-based guidelines for the assessment of overweight and
obesity in the clinical setting have been endorsed in national
guidelines (5). It has also been demonstrated that the tendency
to misperceive BMI status affects physicians (28). Furthermore,
the BMI cutoffs used to classify adults as overweight were low-
ered by the Centers for Disease Control and Prevention from
27.8 for men and 27.3 for women to 25.0 kg/m2 for all adults (5).
Physicians who were not aware of this change may have been
less likely to diagnose overweight patients as such until they
reached a greater BMI. Alternatively, these results may reflect
the tendency for physicians to skip making a clinical diagnosis
of overweight; it is plausible that physicians may be prioritizing
other issues in primary care ahead of documenting overweight
as a clinical diagnosis. This possibility is even more compelling
when considering that physicians often cite lack of time as a
barrier to the delivery of weight management counseling in
To investigate secular trends in physician-directed weight
loss, directed weight loss among those with hypertension and
hypercholesterolemia was evaluated. Overweight and obese
individuals with hypertension and overweight individuals
with hypercholesterolemia were significantly less likely to be
directed to lose weight by a physician across time. It is possible
that the pessimism among physicians in primary care about
the efficacy of weight loss counseling (11,12) may be contribut-
ing to these trends. Furthermore, reports indicate that the use
of antihypertensive medication (33) and lipid-lowering agents
(34) has increased significantly during the past two decades.
The widespread popularity and selection of medications to
manage obesity-related comorbidities, combined with the lack
of pharmaceutical treatment options for weight management,
are likely contributing to the tendency among physicians to
address weight-related comorbidities with pharmaceutical
options rather than with weight reduction, even though weight
reduction as a treatment for hypertension and hypercholeste-
rolemia is endorsed by national guidelines (35,36).
A growing body of evidence suggests that provider-directed
weight reduction is associated with greater intentions to lose
weight and commencement of weight loss among patients
(8,10,17), and patients with whom the physician has greater
contact are more likely to be counseled on weight loss (12,18).
Though physician involvement in weight management is by
no means fulfilled by diagnosing a patient as overweight or
prescribing weight loss, the monitoring of these behaviors
nonetheless provides an indication of how the weight
management practices of US physicians are changing over
time. In this analysis, we observed that physicians are no
more likely to engage in weight management practices with
their patients across time, despite the rise in obesity and the
greater frequency of visits to primary care by obese adults
compared to their normal weight counterparts (37). However,
numerous barriers to weight-related counseling have been cited
frequently by physicians, including lack of time (11,29), lack
of reimbursement (13,29), and poor confidence, knowledge,
and experience in weight-related counseling (11,13,14); these
factors may, in part, explain the stagnant rates of provider-care
of obesity. Additionally, though Medicare policy was revised in
2004 stipulating the removal of language inferring that obesity
shall not be considered an illness (38), research indicates that
little more than financing bariatric surgery for patients with
comorbid conditions is available as a treatment option for
obesity (39). Medicaid coverage of obesity assessment and
treatment in primary care is reflective of the limited scope
of the Medicare policy (39). The secular interplay of obesity-
related action among physicians in primary care and cited
barriers warrants further investigation.
Several limitations of this analysis exist. Although the use
of multiple surveys allowed for the evaluation of trends over
time, it also introduced potential inconsistencies between
questionnaires because of varying survey protocols, and the
unavailability of data in some surveys limited the secular eval-
uation of some analyses. Another inherent limitation is the use
of self-reported data. Though the potential for respondents to
misreport information is a possibility, alternative methods for
collecting information on physician activity were not available.
Moreover, there were few questions assessing care of excess
weight available in NHANES; thus, we were unable to address
care of overweight, obesity, and abdominal obesity, as separate
entities and how recent physician diagnosis of overweight and
physician-directed weight loss are not known. Additionally,
changing treatment option availability for obesity and obesity-
related comorbidities over time introduces the possibility of
inconsistency in the physician-directed weight loss variables.
Furthermore, a large portion of the combined sample was
excluded from analysis (missing data for age, sex, and BMI),
and we were unable to weight the multivariate analyses; thus,
these results cannot be generalized to the US population.
This study illuminates the lack of physician and individual
diagnosis of overweight and direction of weight loss between
1994 and 2008. Surveillance of trends over time calls attention
to the scarcity in the care of obesity in the United States and
provides the support needed for physicians, individuals, and
policy makers alike to address the deficiencies in the diagno-
sis and treatment of obesity in the primary care setting and
J.L.K. and E.A.Y. designed the study and acquired the data from the
NIH. Additionally, E.A.Y. performed the statistical analysis and wrote the
introduction, methods, results, and discussion sections of the manuscript.
6 Download full-text
J.L.K. and A.K.M. reviewed the data and analysis, edited the text, and
designed the presentation of data (tables and figures). All three authors
approved the final manuscript. There was no funding source for this
The authors declared no conflict of interest.
© 2011 The Obesity Society
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