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Clinical Review: Modified 5 As: Minimal intervention for obesity counseling in primary care.

Dalhousie University, Family Medicine, Suite 4060, Lane Bldg, 5909 Veteran's Memorial Lane, Halifax, NS B3H 2E2. .
Canadian family physician Medecin de famille canadien (Impact Factor: 1.34). 01/2013; 59(1):27-31.
Source: PubMed
ABSTRACT
To adapt the 5 As model in order to provide primary care practitioners with a framework for obesity counseling.
A systematic literature search of MEDLINE using the search terms 5 A's (49 articles retrieved, all relevant) and 5 A's and primary care (8 articles retrieved, all redundant) was conducted. The National Institute of Health and the World Health Organization websites were also searched.
The 5 As (ask, assess, advise, agree, and assist), developed for smoking cessation, can be adapted for obesity counseling. Ask permission to discuss weight; be nonjudgmental and explore the patient's readiness for change. Assess body mass index, waist circumference, and obesity stage; explore drivers and complications of excess weight. Advise the patient about the health risks of obesity, the benefits of modest weight loss, the need for a long-term strategy, and treatment options. Agree on realistic weight-loss expectations, targets, behavioural changes, and specific details of the treatment plan. Assist in identifying and addressing barriers; provide resources, assist in finding and consulting with appropriate providers, and arrange regular follow-up.
The 5 As comprise a manageable evidence-based behavioural intervention strategy that has the potential to improve the success of weight management within primary care.

Full-text (PDF)

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This article has been peer reviewed.
Can Fam Physician
2013;59:27-31
Modied 5
A
s
Minimal intervention for obesity counseling in primary care
Michael Vallis PhD RPsych Helena Piccinini-Vallis MD MSc CCFP Arya M. Sharma MD PhD FRCPC Yoni Freedhoff MD CCFP
Abstract
Objective  To adapt the 5 As model in order to provide primary care practitioners with a framework for obesity
counseling.
Sour ces of information  A systematic literature search of MEDLINE using the search terms 5 As (49 articles
retrieved, all relevant) and 5 As and primary care (8 articles retrieved, all redundant) was conducted. The National
Institute of Health and the World Health Organization websites were also searched.
Mai nmessage  The 5 As (ask, assess, advise, agree, and assist), developed for smoking cessation, can be adapted
for obesity counseling. Ask permission to discuss weight; be nonjudgmental and explore the patients readiness
for change. Assess body mass index, waist circumference, and obesity stage; explore drivers and complications
of excess weight. Advise the patient about the health risks of obesity, the benefits of modest weight loss, the need
for a long-term strategy, and treatment options. Agree on realistic weight-loss expectations, targets, behavioural
changes, and specific details of the treatment plan. Assist in identifying and addressing barriers; provide resources,
assist in finding and consulting with appropriate providers, and arrange regular follow-up.
Conclusion The 5 As comprise a manageable evidence-based behavioural intervention strategy that has the
potential to improve the success of weight management within primary care.
Mr Cortez is a 57-year-old man with type 2 diabetes and hypertension. He has been gaining weight since retiring from
the military. His body mass index (BMI) is 37.4 kg/m
2
, and you are frustrated that he has not followed your recommenda-
tions to lose weight. During his most recent visit you told him that if he did not lose weight he faced a future of disability
from diabetes. You are concerned about him but wonder if talking about weight is a good use of time. What should your
approach be?
Sources of information
A systematic literature search of MEDLINE using the search terms 5 As (49 articles retrieved, all relevant) and 5 As
and primary care (8 articles retrieved, all redundant) was conducted. The National Institute of Health and the World
Health Organization websites were also searched.
Main message
Primary care is an important setting for obesity management.
1
Yet many primary care providers feel ill-equipped
or inadequately supported to address obesity.
2-9
This is in part because obesity outcomes depend more on
patient behaviour than on physician recommendations and educa-
tion. Behaviour change theories exist, as does evidence that behaviour
change interventions are effective.
10,11
However, the time and support
necessary to learn behavioural counseling are barriers. In this context,
minimal intervention strategies such as the 5 As (ask, assess, advise,
agree, and assist) can guide the process of counseling a patient about
behaviour change.
The 5 As, developed for smoking cessation,
12
can be adapted for
obesity counseling.
13,14
The 5 As are appealing, as they are rooted in
behaviour change theory (eg, self-management support, readiness
assessment, behaviour modification, self-efficacy enhancement) and
can be implemented in busy practice settings.
However, recent studies show that they are only
partially implemented: ask and advise are used
KEY POINTS
Primary care is an important
setting for obesity management, yet many
primary care providers feel ill-equipped or
inadequately supported to address obe-
sity. Minimal intervention strategies such
as the 5 As (ask, assess, advise, agree, and
assist) can guide the process of counseling
a patient about behaviour change. They are
rooted in behaviour change theory and can
be implemented in busy practice settings.
Clinical Review
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but not agree and assist.
13-15
Nevertheless, when used,
agree and assist were related to diet improvement,
and advise was related to increased motivation and
condence to change dietary fat intake and to lose
weight.
13
The 5 As are also appealing because they enable
providers to raise the issue of obesity, and they can
be incorporated into recent obesity classification and
assessment models.
Ask. Asking questions (and minimizing state-
ments) is a principle of motivational interviewing,
an evidence-based interviewing style that facilitates
patient-driven behaviour change.
16-18
Ideal initial ques-
tions should seek permission to talk about weight,
such as, “Are you concerned about your weights effect
on your health or your quality of life?” and Would it
be alright if we discussed your weight?” This is impor-
tant because body weight is a sensitive topic for most
owing to embarrassment, fear, blame, and stigma, and
weight bias exists among physicians, dietitians, nurses,
and psychologists.
19-23
With permission to talk about weight, a nonjudg-
mental (another core principle of motivational inter-
viewing) conversation is more likely. Nonjudgmental
curiosity helps avoid challenges to effective communi-
cation. It is important not to make assumptions about
the patient’s lifestylemany obese patients might
already be working hard at weight management.
Language is also important. The term obesity might
be perceived negatively by some patients.
24
Research
suggests that patients prefer the term weight.
25
Asking
about lifestyle, relationship with food, motivation, etc,
reduces any tendency toward biased assumptions,
such as unhealthy weight equating with unhealthy
lifestyle. Asking can be educational, as in the ques-
tion, “What do think you could do to better manage
your weight?”
An important early step when asking is assess-
ing patient readiness to manage weight. Readiness
can be assessed by general questions (such as, “Are
you ready to try to work on your weight? followed
by, Would you be comfortable if I tried to help?”), a
readiness ruler (a 10-cm visual analogue scale), or
Prochaska’s Stages of Change model (ie, precontem-
plation, contemplation, preparation, action, mainte-
nance).
26
Assessing readiness establishes where the
patient is and helps the physician avoid working
harder than the patient.
If patients are unwilling or reluctant to talk about
weight (asking a question obliges one to listen to the
answer), the physician can summarize that this indi-
cates the patient is comfortable with their weight. One
can then reassure the patient that if weight becomes a
concern the issue can be revisited.
You ask Mr Cortezs permission to discuss his weight.
He appears relieved by your nonjudgmental attitude.
He shares your concern and frustration and men-
tions that he downloaded a food diary app, which he
stopped using after a few days owing to lack of moti-
vation, and that he has been trying to order healthier”
foods at his office cafeteria.
Assess. Asking elicits important information from the
patient. This leads naturally to the second A: assess.
It is important to assess health status (BMI, waist cir-
cumference), the effects of weight on psychosocial
factors, and root causes of obesity. Health status
can be assessed using the Edmonton Obesity Staging
System,
27
which ranks patients (stages 0 to 4) based on
weight-related medical, psychological, and functional
limitations and predicts mortality better than BMI.
28,29
Psychosocial and root-cause factors can be further
assessed using the 4 Ms framework: mental health,
mechanical, metabolic, and monetary factors.
30,31
Mr Cortez has class 2, stage 2 obesity based on his BMI
and health status, respectively. In addition, you nd
symptoms of atypical depression (increased appetite,
lack of interest, feelings of worthlessness) that appear
to be related to his retirement.
Following assessment the physician can introduce
the possibility of change (weight management)—that
is, advise.
Advise. Asking and assessing establish a collabora-
tive relationship in which the complexity of obesity
is identified for the individual. The next step is to ask
permission to give advice—ie, offer a clinical manage-
ment plan (eg, “Now that we have a better understand-
ing of your situation, can I recommend a plan of action
to improve things?”). Patients are likely more receptive
when advising follows asking and assessing (another
principle of motivational interviewing called express-
ing empathy).
Weight-management advice can be complicated.
Current guidelines suggest that all obese patients
should be advised to lose weight, but this recom-
mendation is not based on strong evidence. Given
the high rates of recidivism, common unhealthy
weight-management practices, the negative health
and emotional consequences of weight cycling, and
the need for ongoing support for weight-loss mainte-
nance, it might be prudent to limit weight-loss advice
to individuals experiencing weight-related complica-
tions (stages 1 to 4 of the Edmonton Obesity Staging
System).
27
Emphasizing personal obesity risks and the
benefits of modest sustained weight loss (5% to 10% of
initial weight)
32
can be helpful. Those in stage 0 might
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Clinical Review
benefit from advice to avoid weight gain and reassur-
ance that, regardless of their weight, there are tre-
mendous benefits to healthier lifestyles and that the
weight-independent benefits of healthy diets, stress
management, adequate sleep, and regular physical
activity will mitigate many of excess weight’s associ-
ated risks. It is also crucial to point out the chronic
relapsing nature of obesity that necessitates a long-
term weight-management strategy.
Finally, patients should be advised about treatment
options, including lifestyle monitoring, behavioural and
psychological counseling, medications, low-calorie
diets, and bariatric surgery. This is also the time to
discuss the benefits and shortcomings of commercial
weight-loss programs.
Given Mr Cortez’s stage 2 obesity and his depression,
you advise him to consider self-monitoring with a food
journal, activity log, and regular weighing to help pre-
vent further weight gain. You also suggest he meet with
a psychologist for further help with his mood.
Agree. Before proceeding with treatment, it is impor-
tant to obtain explicit agreement about the treatment
plan—that is, the patient’s buy-in. Although the physi-
cian might believe he or she is in the best position to
determine the most effective course of action, it is the
patient who must do the work of change. That is why
the agree step is so important. Just as many patients
might require multiple conversations before they can
agree with a physicians recommendations, many phy-
sicians might need to modify their recommendations
in order to establish treatment plans that particular
patients are comfortable following. The agree step is
about respectful negotiation.
Research shows that most patients have unreal-
istic weight-loss expectations and are discouraged
when these unrealistic goals cannot be achieved. It
has therefore been suggested that patients attempt
to achieve a “best” weight that is achievable and sus-
tainable while still enjoying life.
33
Setting goals sur-
rounding weight-management behaviourand not
weight itselfmight help patients achieve a mean-
ingful weight loss as, ultimately, it will be behaviour
changes that will get them there.
Any treatment plan should use effective behaviour
modification principles such as goal setting and behav-
iour shaping. Goal setting is easily done using the
SMART framework (find behavioural goals that are spe-
cific, measurable, achievable, rewarding, and timely).
34
Shaping involves sequencing goals that are meaning-
ful and achievable, so that patients experience success
and enhanced self-efficacy.
It is important to focus on improving mental and
physical health rather than on kilograms lost—success
will look different for each patient. Agreement should
also be reached about any additional aspects of the
treatment plan (eg, adherence to medications, learning
more about bariatric surgery, etc).
Mr Cortez appears sceptical about seeing a psy-
chologist, as he does not think he is depressed.
After you explain that this is not an uncommon
problem and might well be an important cause
of his weight gain, he agrees to meet with the
psychologist. He also agrees that, for now, simply
avoiding further weight gain could be seen as the
first sign of “success.”
Assist. After agreeing on treatment objectives, physi-
cians should assist patients by identifying and address-
ing facilitators (eg, motivation, support) and barriers
(eg, social, medical, emotional, and economic barriers
that can make weight management challenging)
35
to
the treatment plan. Consistent with minimal interven-
tion, assisting does not mean that the physician does
the work. In fact, given the reality of primary care set-
tings, the role of the assisting physician is to identify,
educate, recommend, and support.
Patients should be assisted in identifying and seek-
ing out credible weight-management resources and be
referred to appropriate providers for management (ie,
emphasizing an interdisciplinary approach). Arranging
follow-up is important so that the support of the physi-
cian recommendations can continue.
Mr Cortez responded well to the 5 As. By asking per-
mission you were able to identify his communication
challenges (your frustration and his fear of judgment).
After clarifying your interest he disclosed that he was
worried about weight gain. Once you understood that
his depression was due to the loss of his work role,
which he coped with by eating, he was open to your
recommendations. After agreeing that he seek help
from a local community-based healthy living resource,
he began to take action.
Conclusion
Primary care is a hub for supporting realistic weight-
management interventions. Yet the work of behaviour
change cannot be taken on solely by the physician.
The ideal role for the physician is to start sensi-
tive conversations, achieve agreement on following
through with effective weight-management strate-
gies, and support the patient in the initiatives that he
or she undertakes. The 5 As, summarized in Table 1
34
and Figure 1,
27,34
comprise a manageable evidence-
based behavioural intervention strategy that has the
potential to improve the success of weight manage-
ment within primary care.
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Dr Vallis is Associate Professor of family medicine and psychiatry and
Adjunct Professor of psychology at Dalhousie University, and Lead of the
Behaviour Change Institute at Capital Health in Halifax, NS. Dr Piccinini-
Vallis is Clinician Investigator in the Department of Family Medicine at
Dalhousie University. Dr Sharma is Scientific Director of the Canadian
Obesity Network and Professor and Endowed Chair in Obesity Research and
Management at the University of Alberta in Edmonton. Dr Freedhoff is the
founder and Medical Director of the Bariatric Medical Institute in Ottawa, Ont,
and Assistant Professor of Family Medicine at the University of Ottawa.
Acknowledgment
We thank the following individuals who provided their time as well as criti-
cal feedback and assessment of the 5 As method as part of the Canadian
Obesity Network’s Primary Practice Working Group: Geeta Achytutan, MD,
CCFP (Regina, Sask), Eleanor Benterud, RN, MN (Calgary, Alta), Andrew
Cave, MD, FCFP, FRCGP (Edmonton, Alta), Cyd Courchesne, OMM, CD,
MD, DAvMed, CHE (Ottawa, Ont), Heather Davis, MD, FRCPC (Halifax, NS),
Robert Dent, MD CM, FRCPC (Ottawa, Ont), Eric Doucet, PhD (Ottawa, Ont),
Angela Estey, RN, MSc (Edmonton, Alta), Mary Forhan, OT, PhD (Hamilton,
Ont), Tracey Hussey, MSc, RD (Hamilton, Ont), Marie-France Langlois, MD,
FRCPC, CSPQ (Sherbrooke, Que), Patricia Marturano (Mississauga, Ont),
Rick Tytus, MD, CCFP (Hamilton, Ont), Shahebina Walji, MD, CCFP (Calgary,
Alta), Sean Wharton, MD, FRCPC (Hamilton, Ont), Ron Wilson, MD, CCFP
(Mississauga, Ont).
Contributors
This article was developed out of the Canadian Obesity Networks
Primary Practice Working Group. Dr Vallis wrote and edited the
article. Drs Piccinini-Vallis, Sharma, and Freedhoff reviewed the drafts
and contributed to the adaptations of the 5 As model.
Figure 1. The 5 As for obesity counseling
ASK
Ask permission to discuss weight:
“May I talk to you about your weight?”
Are you concerned about the effects of your weight on your
health or quality of life?”
“Would it be alright if we discussed your weight?”
Be sure to afrm that you hear what the patient says
Explore readiness to change:
Are you ready to work on your weight? Would it be okay if I helped?”
“How important is it for you to work on your weight?”
“How condent are you that you can take action on your goal?
ASSESS
Assess health status, BMI, waist circumference, waist-hip
ratio, root causes of weight gain, and effects of weight on
psychosocial functioning
Use the Edmonton Obesity Staging System
27
ADVISE
Advise about the risks of obesity; explain the benets of
modest weight loss and the need for long-term strategies
“Now that we have a better understanding of your situation,
can we explore and come up with a plan of action to improve
things?”
Explore all treatment options
AGREE
The agree step is about respectful negotiation to achieve
“best weight” focused on SMART
34
goals and health
outcomes
Any treatment plan should use effective behaviour modica-
tion principles such as goal setting and behaviour shaping
ASSIST
Address facilitators (motivation, support) and barriers
(social, medical, emotional, and economic) that make
weight management challenging
The clinician’s role is to identify, educate, recommend, and
support
Arrange follow-up to keep the conversation going
BMI—body mass index, SMART—specic, measureable, achievable,
rewarding, timely.
Table 1. The 5 As of obesity management
A DEFINITION RATIONALE
Ask Ask permission to discuss
weight; be nonjudgmental;
explore readiness for
change
Weight is a sensitive issue;
avoid verbal cues that
imply judgment; indication
of readiness might predict
outcomes
Assess Assess BMI, WC, obesity
stage; explore drivers and
complications of excess
weight
BMI alone should never
serve as an indicator for
obesity interventions;
obesity is a complex and
heterogeneous disorder
with multiple causes—
drivers and complications
of obesity will vary among
individuals
Advise Advise on health risks of
obesity, benets of modest
weight loss, the need for a
long-term strategy, and
treatment options
Health risks of excess
weight can vary;
avoidance of weight gain
or modest weight loss can
have health benets;
considerations of
treatment options should
account for risks
Agree Agree on realistic weight-
loss expectations and
targets, behavioural
changes using the SMART
framework,
34
and specic
details of the treatment
options
Most patients and many
physicians have unrealistic
expectations; interventions
should focus on changing
behaviour; providers
should seek patients’ “buy-
in” to proposed treatment
Assist Assist in identifying and
addressing barriers;
provide resources and
assist in identifying and
consulting with
appropriate providers;
arrange regular follow-up
Most patients have
substantial barriers to
weight management;
patients are confused and
cannot distinguish credible
and noncredible sources of
information; follow-up is
an essential principle of
chronic disease
management
BMI—body mass index; SMART—specic, measurable, achievable,
rewarding, timely; WC—waist circumference
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Competing interests
Dr Freedhoff is the cofounder of Bariatric Medical Institute, coauthor,
with Dr Sharma, of Best Weight: A Practical Guide to Office-Based Obesity
Management, and author of Why Diets Fail and How to Make Yours Work. None
of the other authors has any competing interests to declare.
Correspondence
Dr Michael Vallis, Dalhousie University, Family Medicine, Suite 4060,
Lane Bldg, 5909 Veterans Memorial Lane, Halifax, NS B3H 2E2;
telephone 902 789-9545; e-mail tvallis@dal.ca
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    • "Future research should evaluate whether weight-related stigma not only affects recommendations but also how stigma in general might influence the quality of counseling (e.g., informed consent about possible risk related to surgery) or follow-up examinations by the physician. Possible intervention such as the B5As^ of obesity should aim to inform HCPs with different backgrounds about bariatric surgery as a part of obesity management and to improve physician-patientinteraction in order to assure integrated treatment and counseling373839. "
    [Show abstract] [Hide abstract] ABSTRACT: Background: Despite reported effectiveness, weight loss surgery (WLS) still remains one of the least preferred options for outpatient providers, especially in Germany. The aim of this study was to examine the effect of stigma and knowledge on recommendation of WLS and referral to a surgeon by general practitioners (GPs) and internists. Method: The sample consists of 201 GPs and internists from Germany. The questionnaire included questions on the perceived effectiveness of WLS, the frequency of recommendations of WLS, and the frequency of referral to WLS. Stigma, as well as knowledge was also assessed in this context. Linear and logistic regression models were conducted. A mediation analysis was carried out within post hoc analysis. Results: Knowledge (b = 0.258, p < 0.001) and stigma towards surgery (b = -0.129, p = 0.013) were related to the frequency of recommendation of WLS. Additionally, respondents, who were more likely to express negative attitudes towards WLS, were less likely to recommend WLS and thus refer patients to WLS (b = -0.107, p < 0.05). Furthermore, respondents with more expertise on WLS were more likely to recommend and thus refer patients to WLS (b = 0.026, p < 0.05). Conclusion: This study showed that stigma plays a role when it comes to defining treatment pathways for patients with obesity. The question remains how this might influence the patients and their decision regarding their treatment selection. Interventions are required to make treatment decisions by physicians or patients independent of social pressure due to stigma.
    Full-text · Article · Feb 2016 · Obesity Surgery
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    • "Furthermore, well-designed patient education and self-management interventions have been found to significantly improve health outcomes for several conditions [77]. The common thread between different self-management approaches that strive to provide more effective guidance for clinicians and their patients is the use of strategies that facilitate collaborative decision-making, problem-solving and goal setting54555657. While these approaches have been widely endorsed79808182 as a unifying framework for behavioural counselling in primary care83848586 , the selection of the best approach will depend on the clinical context [87,88]. "
    [Show abstract] [Hide abstract] ABSTRACT: Despite available evidence for optimal management of spinal pain, poor adherence to guidelines and wide variations in healthcare services persist. One of the objectives of the Canadian Chiropractic Guideline Initiative is to develop and evaluate targeted theory- and evidence-informed interventions to improve the management of non-specific neck pain by chiropractors. In order to systematically develop a knowledge translation (KT) intervention underpinned by the Theoretical Domains Framework (TDF), we explored the factors perceived to influence the use of multimodal care to manage non-specific neck pain, and mapped behaviour change techniques to key theoretical domains. Individual telephone interviews exploring beliefs about managing neck pain were conducted with a purposive sample of 13 chiropractors. The interview guide was based upon the TDF. Interviews were digitally recorded, transcribed verbatim and analysed by two independent assessors using thematic content analysis. A 15-member expert panel formally met to design a KT intervention. Nine TDF domains were identified as likely relevant. Key beliefs (and relevant domains of the TDF) included the following: influence of formal training, colleagues and patients on clinicians (Social Influences); availability of educational material (Environmental Context and Resources); and better clinical outcomes reinforcing the use of multimodal care (Reinforcement). Facilitating factors considered important included better communication (Skills); audits of patients' treatment-related outcomes (Behavioural Regulation); awareness and agreement with guidelines (Knowledge); and tailoring of multimodal care (Memory, Attention and Decision Processes). Clinicians conveyed conflicting beliefs about perceived threats to professional autonomy (Social/Professional Role and Identity) and speed of recovery from either applying or ignoring the practice recommendations (Beliefs about Consequences). The expert panel mapped behaviour change techniques to key theoretical domains and identified relevant KT strategies and modes of delivery to increase the use of multimodal care among chiropractors. A multifaceted KT educational intervention targeting chiropractors' management of neck pain was developed. The KT intervention consisted of an online education webinar series, clinical vignettes and a video underpinned by the Brief Action Planning model. The intervention was designed to reflect key theoretical domains, behaviour change techniques and intervention components. The effectiveness of the proposed intervention remains to be tested.
    Full-text · Article · Dec 2015 · Implementation Science
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    • "Practitioners are now encouraged to use the '5As' to manage patients' weight: Ask, Assess, Advise, Assist and Arrange. This intervention style was originally used in smoking cessation (Fiore et al. 2008) and uses evidence-based behaviour change concepts (Vallis et al. 2013). The new guidelines also follow a patient-centred approach, with the intention that the patient will be intrinsically involved in the planning and implementation of their weight management. "
    [Show abstract] [Hide abstract] ABSTRACT: Nearly 62% of primary care patients are overweight or obese, and obesity is now a National Health Priority Area. Weight management interventions in primary care currently generate little more than 1 kg of weight loss per patient over a 2-year period. Consequently, further strategies are required to improve the effectiveness of weight management in primary care. The National Health and Medical Research Council (NHMRC) have released updated guidelines for the management of overweight and obese patients in primary care. However, there is some disconnect between establishment of guidelines and their implementation in practice. Barriers to GPs using guidelines for the management of obesity include low self-efficacy, perceived insufficient time in consultations and the challenge of raising the topic of a patient's weight. Nonetheless, patients prefer to receive weight management support from GPs rather than other health professionals, suggesting that the demand on GPs to support patients in weight management will continue. GPs cannot afford to side-line obesity management, as obesity is likely to be the most prevalent modifiable risk factor associated with patients' long-term health. Without further strategies to support GPs in their management of patients' weight, obesity will continue to be an expensive and long-term public health issue.
    Full-text · Article · Sep 2015 · Australian Journal of Primary Health
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