Highlights
In a nationally representative analysis of US office-based visits by adults with obesity, counseling was far from routine: 21.5% of visits included weight reduction advice, 24.5% exercise counseling, 33.9% dietary counseling, 40.1% any counseling, and only 12.2% all three together.
Preventive visits, chronic problem visits, and visits by patients with hyperlipidemia were more likely to include counseling, suggesting that context and cardiometabolic risk shape physician behavior.
Older adults aged 65 years or older were less likely to receive counseling, highlighting a persistent gap in obesity care for a population with high multimorbidity and functional vulnerability.
Black and Hispanic patients had higher adjusted odds of receiving any counseling than White patients, but overall counseling rates remained low across all groups.
Background
Obesity remains one of the most common and clinically consequential chronic conditions in US ambulatory care. It contributes to type 2 diabetes, hypertension, dyslipidemia, nonalcoholic fatty liver disease, osteoarthritis, obstructive sleep apnea, and several cancers, while also increasing healthcare utilization and mortality risk. Current US and international guidelines consistently recommend that clinicians identify obesity, assess related complications, and use clinical encounters to provide or initiate evidence-based weight management interventions, including nutrition counseling, physical activity guidance, and behavioral support.
Primary care is especially important because it is where obesity is often first recognized, where longitudinal trust can be built, and where preventive counseling can be integrated with management of cardiometabolic disease. Yet routine obesity counseling in office practice has historically been inconsistent. Time pressure, limited reimbursement, uncertainty about counseling efficacy, inadequate training, and stigma all likely contribute. Quantifying how often counseling actually occurs in real-world practice, and in whom, remains clinically relevant for health systems and policymakers alike.
The study by Rubens and colleagues addresses this question using the National Ambulatory Medical Care Survey, a major federal dataset designed to reflect office-based physician care in the USA. The paper provides a contemporary look at counseling patterns during 2011-2018 and identifies demographic and visit-level predictors of receiving advice about weight reduction, exercise, and diet.
Study Design and Methods
Design
This was a retrospective cross-sectional observational study using the National Ambulatory Medical Care Survey (NAMCS) from 2011 through 2018. NAMCS is a nationally representative survey of office-based physician visits in the USA and is commonly used to estimate patterns of ambulatory care delivery.
Population
The analysis included adults aged 18 years or older with obesity who had an office visit during the study period. The abstract reports a weighted estimate of 289,667,549 office visits among obese adults across the 8-year interval. Because NAMCS is visit-based rather than patient-based, the unit of analysis was the office visit, not the individual patient. This distinction matters: frequent healthcare users may contribute multiple visits, and the findings therefore reflect counseling opportunities during encounters rather than the proportion of unique patients ever counseled.
Outcomes
The primary outcomes were documentation of receipt of the following during the visit: weight reduction counseling, exercise counseling, dietary counseling, any counseling, and all three forms of counseling. These outcomes are clinically sensible because obesity treatment guidelines typically emphasize multidomain behavioral management rather than a single message in isolation.
Analysis
The investigators used descriptive statistics and multivariable logistic regression to estimate counseling prevalence and identify predictors. Sampling weights were applied so that results would generate national estimates. Covariates included demographic features, comorbid conditions, visit characteristics, and practice-related factors.
Key Findings
Overall counseling prevalence was low
The most important result is the persistent underuse of obesity counseling in office-based care. Of all visits by adults with obesity, only 21.5% included weight reduction advice. Exercise counseling occurred in 24.5% of visits, and dietary counseling in 33.9%. When collapsed into broader categories, only 40.1% of visits included any type of counseling, while just 12.2% included the full triad of weight, exercise, and diet counseling.
These estimates suggest that even in a clinical population already identified as obese, obesity management advice was absent from most office encounters. The fact that dietary counseling was the most frequent of the three likely reflects its ease of incorporation into general chronic disease care, particularly in patients with diabetes, hypertension, or hyperlipidemia. Still, the low rate of combined counseling is notable because comprehensive behavioral treatment generally requires reinforcement across multiple domains.
Race and ethnicity were associated with counseling likelihood
In adjusted analyses, Black patients had higher odds of receiving any counseling than White patients (OR 1.43, 95% CI 1.11-1.85), as did Hispanic patients (OR 1.48, 95% CI 1.03-2.14). Hispanic patients also had higher odds of receiving all three forms of counseling (OR 2.02, 95% CI 1.09-3.73).
These findings are interesting and somewhat counter to the broader literature on disparities in preventive counseling, where minority populations often experience underdelivery of recommended services. Several interpretations are possible. Clinicians may perceive greater obesity-related risk in these populations, preventive discussions may be more likely in visits focused on metabolic disease, or there may be regional and practice-pattern differences captured in the dataset. Importantly, higher relative odds should not be mistaken for high absolute performance. Counseling remained underused across all racial and ethnic groups.
Older adults were less likely to receive counseling
Adults aged 65 years or older had significantly lower odds of receiving any counseling (OR 0.68, 95% CI 0.49-0.95). This is a clinically important result. Older adults often have obesity complicated by frailty risk, osteoarthritis, sleep apnea, cardiovascular disease, polypharmacy, and functional decline. Although weight loss goals in later life may need to be individualized to preserve muscle and bone mass, this population still stands to benefit from tailored counseling that emphasizes physical function, nutrition quality, and metabolic health.
The lower counseling rate may reflect clinician uncertainty about weight loss targets in older patients, competing demands in complex visits, or assumptions that lifestyle change is less feasible. Yet these are precisely the patients in whom structured, individualized counseling may have substantial benefit when done thoughtfully.
Clinical context strongly influenced counseling
Certain visit characteristics were associated with greater counseling delivery. Hyperlipidemia was linked to higher odds of any counseling (OR 1.82, 95% CI 1.45-2.29). Chronic problem visits also increased the odds of any counseling (OR 1.84, 95% CI 1.44-2.35) and all counseling (OR 2.00, 95% CI 1.41-2.84). Preventive care visits were another strong predictor, associated with higher odds of any counseling (OR 1.67, 95% CI 1.28-2.18) and all counseling (OR 1.76, 95% CI 1.21-2.56).
These results make intuitive sense. When obesity is addressed in the setting of lipid abnormalities or during preventive visits, counseling may be easier to justify and document. They also suggest that clinicians may be more likely to deliver obesity advice when the visit agenda explicitly includes chronic disease prevention or risk reduction. The implication for practice is straightforward: workflows that reserve counseling primarily for annual prevention visits may miss many opportunities during follow-up care.
Continuity may matter
The authors report that the odds of receiving all types of advice were higher when the physician was also the patient’s primary care provider. However, the abstract lists an odds ratio of 1.06 with a 95% confidence interval of 1.21-3.53, which is internally inconsistent because the point estimate falls outside the stated confidence interval. This likely reflects a typographical error in the abstract or a transcription issue. Even so, the direction of the finding aligns with prior evidence that continuity of care improves preventive service delivery, patient engagement, and chronic disease management.
From a clinical perspective, obesity counseling is often iterative rather than one-time. It benefits from trust, repeated follow-up, shared goal setting, and monitoring over time. A stronger patient-physician relationship could reasonably increase the likelihood that weight, exercise, and diet are all discussed in a coherent plan.
Clinical Interpretation
The paper reinforces a familiar but still unresolved problem: obesity is ubiquitous in ambulatory practice, but guideline-concordant counseling remains uncommon. This gap matters because office-based counseling, even when brief, can influence readiness to change, support referrals to dietitians or intensive behavioral programs, and frame obesity as a treatable chronic disease rather than a lifestyle failure.
The findings also underscore that not all counseling opportunities are equivalent. Preventive visits and chronic care encounters appear to be particularly fertile moments for intervention. Embedding obesity counseling prompts into these visit types may therefore be a pragmatic strategy. Examples include automatic body mass index recognition with clinical decision support, brief counseling templates in the electronic record, referral pathways to nutrition services or evidence-based weight-management programs, and team-based models involving nurses, medical assistants, pharmacists, or health coaches.
Another key message is that counseling quality likely matters as much as counseling frequency. NAMCS can identify whether advice was documented, but not whether it was specific, patient-centered, culturally responsive, or linked to follow-up. A checkbox indicating dietary advice is not equivalent to structured counseling using motivational interviewing, caloric and nutritional guidance, exercise prescriptions adapted to functional status, and longitudinal monitoring. Thus, the low prevalence reported here almost certainly underestimates the true implementation gap when judged against what guidelines consider effective treatment.
How the Findings Fit With Existing Guidance
Major clinical guidance supports routine screening and intervention for obesity. The US Preventive Services Task Force recommends screening adults for obesity and offering or referring patients with obesity to intensive, multicomponent behavioral interventions. The American Academy of Family Physicians and major endocrine and obesity societies similarly emphasize lifestyle counseling, behavior change support, and individualized treatment plans, often escalating to anti-obesity pharmacotherapy or bariatric surgery when appropriate.
Against that standard, the counseling rates in this study appear modest. Even the 40.1% rate for any counseling means that most visits by adults with obesity involved no documented behavioral advice at all. The 12.2% rate for comprehensive counseling is especially striking, because diet, physical activity, and weight-management strategy are usually interdependent. In modern obesity medicine, brief advice is only the entry point; longitudinal behavioral treatment and adjunctive therapies are often needed.
Strengths of the Study
This study has several strengths. First, it uses a nationally representative dataset, allowing inference about US office-based care rather than a single health system or payer population. Second, the study period spans 2011-2018, offering a relatively contemporary view of practice patterns before the more recent expansion of anti-obesity pharmacotherapy. Third, the multivariable analysis identifies clinically intuitive predictors that may help health systems target improvement efforts, particularly among older adults and outside preventive visit settings.
Limitations and Cautions
Several limitations should temper interpretation. The study is observational and cross-sectional, so it cannot determine causality. Because the unit of analysis is the visit, results do not indicate the percentage of obese individuals who were ever counseled over time. Documentation is another key limitation: counseling may have occurred but not been captured, or documentation may have been present without meaningful counseling taking place.
The abstract provides only limited detail on how obesity was identified within NAMCS. If obesity was based on measured body mass index, that would strengthen ascertainment; if it relied on diagnostic coding or charted indicators, obesity may have been underrecognized. The analysis also cannot assess counseling intensity, duration, patient receptivity, referral completion, or actual weight-loss outcomes. Finally, the abstract’s statement that counseling was infrequent “particularly for older adults and those with comorbidities” should be read carefully, because hyperlipidemia and chronic problem visits were associated with higher odds of counseling, not lower odds. That wording may oversimplify a more nuanced pattern in which some comorbid contexts increase counseling while older age decreases it.
Implications for Practice and Policy
For clinicians, the practical lesson is not simply to counsel more often, but to normalize obesity treatment as part of routine chronic disease care. Brief, structured, nonstigmatizing counseling can be built into standard workflows. Language matters: clinicians should frame obesity as a chronic, biologically influenced condition and focus on achievable behavior goals, health outcomes, and function rather than willpower alone.
For practices and health systems, the study supports several operational priorities: use visit-based prompts for obesity counseling, create referral pathways to dietitians and intensive behavioral treatment, strengthen continuity with primary care clinicians, and tailor approaches for older adults whose goals may center on mobility, independence, and cardiometabolic stability rather than large weight-loss targets. Payment policy also remains important. Counseling rates are unlikely to improve substantially without time, staffing, and reimbursement structures that support behavioral treatment.
For researchers, the next step is to move beyond whether advice was documented and examine the content, intensity, equity, and outcomes of obesity care in ambulatory settings. With increasing use of glucagon-like peptide-1 receptor agonists and related anti-obesity agents, future studies should also evaluate how behavioral counseling is integrated with pharmacotherapy rather than displaced by it.
Conclusion
This NAMCS analysis shows that obesity-related counseling in US office-based practice remains uncommon despite longstanding guideline recommendations. Only about two in five visits by adults with obesity included any documented counseling, and only one in eight included weight, diet, and exercise advice together. Counseling was more likely during preventive and chronic care visits and less likely among adults aged 65 years or older. The findings point to a durable implementation gap in primary care obesity management and highlight the need for more systematic, team-based, and longitudinal approaches to counseling.
Funding and ClinicalTrials.gov
No funding source is reported in the abstract provided. ClinicalTrials.gov registration is not applicable to this retrospective observational analysis of survey data.
References
Rubens M, Ramamoorthy V, Saxena A, Rodriguez A, Murillo B, Shah K, Tudela C, McCormack-Granja E. Weight Reduction Advice by Physicians for Obese Patients in Office-Based Settings in the USA: An Observational Study. Journal of General Internal Medicine. 2026-05-07. PMID: 42098579. Available at: https://pubmed.ncbi.nlm.nih.gov/42098579/
US Preventive Services Task Force. Weight Loss to Prevent Obesity-Related Morbidity and Mortality in Adults: Behavioral Interventions. JAMA. 2018;320(11):1163-1171.
Jensen MD, Ryan DH, Apovian CM, et al. 2013 AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults. Journal of the American College of Cardiology. 2014;63(25 Pt B):2985-3023.
Wharton S, Lau DCW, Vallis M, et al. Obesity in adults: a clinical practice guideline. CMAJ. 2020;192(31):E875-E891.
American Gastroenterological Association Institute and other multisociety guidance documents increasingly support comprehensive obesity management, including behavioral therapy, pharmacotherapy, and procedural options where appropriate; clinicians should consult current specialty-specific updates for implementation details.
