Nurse Practitionersand the Preventionand Treatmentof Adult ObesityA White Paper of the American Nurse Practitioner FoundationSummer 2013American Nurse Practitioner Foundation12600 Hill Country Blvd.Suite R-275Austin, TX

BackgroundAccording to the latest data available from the UnitedStates Centers for Disease Control and Prevention, theproportion of American adults in the United States classifiedas obese (defined by a body mass index [BMI] 30 kg/m2)in the year 2009 – 2010 had risen to an alarming high of35.7% (Ogden, Carroll, Kit, & Flegal, 2012). Due to thishigh prevalence, obesity has become a significant nationalhealth concern because of its contribution to the leadingcauses of preventable death and its associated health carecosts. Obesity is now recognized as a chronic disease whichrepresents a dysmetabolic, proinflammatory state associatedwith external and internal physiological and psychologicalsyndrome, diabetes, hypertension, dyslipidemia, depression,and sleep apnea, and those contributing to certain cancersincluding breast, endometrial and colon cancers (Ogden,Carroll, Kit, & Flegal, 2012).Obesity also contributes to a significant proportion of theU.S. domestic medical costs. The medical costs associatedwith obesity in the United States in 1995 were estimatedat 79 billion; by 2008, obesity-associated medical costshad risen to an estimated 147 billion, of which nearly 50%was paid by Medicaid and Medicare. During this same year,the medical costs for obese individuals were estimated tobe 1,429 higher than for individuals of normal weight(Finkelstein, Trogdon, Cohen, & Dietz, 2009).stressors. Patients with severe obesity (BMI 35 kg/m2) are atWhile there are no significant differences between menhigh risk for significant obesity-related comorbidities as welland women in overall prevalence of obesity at any age,as physical and psychological disabilities and stressors thatwomen have the highest prevalence of class 2 (BMI 35affect length and quality of life (Dickerson, 2001). Seriouskg/m2) and class 3 (BMI 40 kg/m2) obesity (See Table 1).obesity-related comorbidities include those contributing toThe age-adjusted prevalence of class 2 obesity in womenatherogenic cardiovascular disease such as the metabolicis 18.3% compared with 12.5% of men. The age-adjustedTable 1: BMI FormulaBMI is calculated with the following formulas. BMI 703 x weight (lb) / height2 (in2) or BMI Weight (kg) / height2 (m2)For example, a man of 5’11”, weighing 172 pounds would be calculated as follows:703 x 172 / 712 703 x 172 / 5041 23.98 BMIDefinitions of BMI: Adults Aged 20BMI18.5 to 24.925 to 29.930 – 34.935 – 39.940 Summer 2013ClassificationNormal weightOverweightClass 1 ObesityClass 2 ObesityClass 3 Extreme ObesityDefinitions of BMI: Children and AdolecentsBMIAt or above the 85th percentileAt or above the 95th percentileClassificationOverweightObese2

prevalence of class 3 obesity (BMI 40 kg/m2) is 6.2%than 1 in 10 African Americans (13.1%) compared within men compared with 8.2% of women (Flegal, Carroll,an estimated 1 in 20 White (5.7%) and Hispanic (5%)Kit, Ogden, 2012). In women, research has demonstratedAmericans (Ogden, Lamb, Carroll, & Flegal, 2010).a 93.2-fold increased relative risk for type 2 diabetes asSignificant gender differences in the associations betweenBMI exceeds 34 kg/m2 (Chan, et al. 1994). Obesity tendsincome and obesity have been identified. Among men,to increase with age such that adults aged 60 and older areobesity prevalence is generally similar at all income levels,more likely than younger adults to be classified as obese.with a tendency for BMI to be slightly higher at higherThis is especially true among women, as 42.3% of womenincome levels. Among women, the opposite is true in thataged 60 and older are obese compared to 31.9% of womenobesity prevalence increases as income level decreases.aged 20-39 (Ogden, Carroll, Kit, & Flegal, 2012).Similarly, level of education is correlated with obesity suchSocioeconomic Impactthat among both men and women, those with a collegedegree have a lower prevalence of obesity compared to menObesity affects individuals across the entire spectrumand women who report earning less than a college degree.of socioeconomic levels. Of the estimated 72.5 millionMoreover, college educated women are less likely to beadults who are obese, 41% (30 million) have incomes at, orobese compared with women with less than a high schoolabove, 350% of the poverty level; 39% (28 million) reportdiploma. However, between the years 1988-1994 and theincomes between 130% and 350% of the poverty level, andyears 2005-2008, the prevalence of obesity increased in20% (15 million) have incomes below 130% of the povertyadults at all income and educational levels (Ogden, Lamb,level. The majority of obese adults are non-Hispanic WhitesCarroll, & Flegal, 2010).with incomes at or above 130% of the poverty level. TheGiven the negative health outcomes and associatedprevalence of obesity is evenly distributed between men andhealthcare costs of obesity, it is important for nursewomen with an estimated 21 million non-Hispanic Whitepractitioners (NPs) and other healthcare professionals tomen and 21 million non-Hispanic White women with BMIsinitiate evidence-based strategies to prevent and treat obesity 30 (Ogden, Lamb, Carroll, & Flegal, 2010).in adult and pediatric patients. To facilitate the role of the NPAfrican Americans are disproportionately affected byin obesity management and to serve as a resource for NPs,obesity: Prevalence of obesity for African Americansthe American Nurse Practitioner Foundation convened ais nearly twice that found in Hispanic and White adultpanel of nurse practitioners in San Francisco on January 12,populations (approximately 50% for African American2013, to discuss prevention and treatment strategies whichadults compared with 30% in Hispanic adults and 30% inNPs can easily implement in their practice settings. SpecificWhite adults). Extreme obesity (BMI 40) affects morerecommendations and strategies identified from this panelSummer 20133

Table 2: Ten Steps to Assessing & Treating Obesity1. Measure height and weight.2. Measure waist circumference.3. Assess comorbidities.4. Based on information obtained in Steps 1-3, determine if patient should be treated.5. Is the patient ready and motivated?6. Which diet should be recommended?7. Discuss a physical activity goal.8. Review the weekly food and activity diary.9. Give the patient copies of dietary information.10. Record patient’s measurements and goals and schedule follow up in 2 to 4 weeks.From: National Institutes Of Health. Clinical guidelines for the identification, evaluation, and treatmentof overweight and obesity in adult patients.discussion, as well as best practice recommendations, are(Flocke, Clark, Schlessman, & Pomiecko, 2005), whereaspresented in this white care providers are more likely to “medicalize”Initiating Treatment of AdultObesityobesity and discuss weight as a medical problem or asGiven the high prevalence of obesity in the United States,health care providers play a critical role in the managementof obesity. While research has shown that patients are morelikely to try to lose weight and to have greater weight losssuccess if they have been advised by their health care providerto lose weight, research has also shown that only 27% to42% of obese patients seeking medical help are advisedto lose weight (Galuska, Will, Serdula, & Ford, 1999).Further, when discussions related to weight managementoccur between patients and providers, the perspectives andexpectations about weight management differs betweenpatients and health care providers. Discussions aboutweight management initiated by patients are more likelyto focus on obtaining advice and assistance from providersSummer 2013an exacerbating factor for their medical problems. Thesedifferences in perspectives and in expectations may resultin lower quality, time, and content of weight managementdiscussions. Some clinicians offer overly simplistic adviceand do not provide the information and support that patientsneed to lose weight. In the panelists’ experiences, however,few patients schedule appointments specifically to discussweight management; multiple factors and barriers affectthe quality of and length of time spent on patient-providerweight loss discussions.Reported barriers to discussing weight managementwith patients among health care providers include issuesassociated with time constraints, insufficient knowledgeof appropriate diet, nutrition and physical activityrecommendations as well as the weight of the provider. Priorto initiating a discussion about weight management with4

patients, the panelists recommend that NPs take stock ofor more than, the patient. In these cases, the conversation istheir personal feelings about obesity. There is research thatpotentially more sensitive and is less likely to occur becausesuggests that many health care providers attribute negativeof the provider’s discomfort about weight and a sense thatstereotypes and negative attributes to obese patients. Forhe or she cannot be an adequate role model.example, many health care providers feel that obesity is theEither the patient or the NP may initiate a conversationpatients’ fault, that obese patients lack willpower, are lazy,about losing weight or obesity. Weight management in theor are unintelligent (Ruelaz et al., 2007). Complicating thisprimary care setting is one of the most difficult settings inissue is the fact that many NPs themselves struggle withwhich to initiate and facilitate behavioral change for a hostissues of weight or obesity, and thus may themselves be onof reasons, including the fact that the clinician and patientthe receiving end of negative stereotypes or may find thatmust be knowledgeable about nutrition and dietary options;they project their own biases and self-image on to patients.obesity is affected by emotional, psychological, societal,Recent research has shown that a health care provider’sand environmental factors; and obesity is a life-long, chronicexcess weigh affects the provider’s willingness to broachcondition that requires multiple support interventions andthe topic of weight management with patients (Bleich,resources. (Wing et al., 2001)Bennett, Gudzune, & Cooper, 2012).Once a decision has been made to manage weight, anyIn this study, Bleich and colleagues found that physiciansassessment of overweight or obesity treatment beginswho were overweight or obese were significantly less likelywith three components: 1) an assessment of risk, 2) ato discuss weight loss with obese patients than physiciansdiscussion with the patient about his or her weight, and 3)with a normal BMI. In another recent study, a physicians’recommendations for treatment goals.gender was a determinant of whether patients received weightTo facilitate a discussion with the patient about obesityloss counseling: Female physicians were more likely toand weight management, the NP may find it helpful torecommend weight loss to overweight/obese patients, moreobtain clinical data to assess risk, including weight andfrequently provide weight loss counseling, and were moreheight to calculate BMI (see Table 2), waist circumference,likely to refer patients to a weight loss program than malecurrent prescribed and over-the-counter medications,physicians (Dutton et al., in press). NPs who are overweightand possible comorbidities in order to begin determiningthemselves might talk about their own experiences withoptimal treatment strategies (National Institutes of Health,being overweight or obese if they are comfortable. In the1998). Medications used to treat chronic disease, includingpanelists’ experiences, a few words of empathy such asantipsychotics and antidepressants, treatments for type“I struggle with my own weight” can be comforting and2 diabetes, medications used for pain management andmotivating to patients. Some providers weigh as much as,selected chemotherapeutic mediations such as tamoxifenSummer 20135

and aromatase inhibitors may cause obesity (Hutfless S, etis a highly metabolically active endocrine organ whoseal., 2013).main products of secretion, adipokines, have essential rolesAs BMI is not a direct measure of adiposity, additionalin energy metabolism; cell viability; control of feeding;diagnostic tools that may be useful in refining risk assessmentthermogenesis; neuroendocrine function; reproduction;and treatment options may include the use of bioelectronicimmunity, and cardiovascular function. (See Figure 1.)impedance analysis (BIA), which assesses the amountStarting the Conversation AboutWeight Managementof body fat and lean body mass which provides a moreaccurate assessment of obesity than the BMI alone (Lee& Gallagher, 2008). A dual-energy X-ray absorptiometry(DEXA) scan, which estimates lean body mass, fat mass,and bone mass, has the advantage of determining bodycomposition for specific anatomic regions (e.g., the legs orarms) and distinguishes visceral fat from subcutaneous fatdepositions (Lee & Gallagher, 2008). Visceral adipose tissueInitiating the conversation with an overweight or obesepatient may be difficult and potentially fraught with emotionand the stigma associated with obesity. The panelistsrecommend a number of strategies to minimize the patient’spotential discomfort or perceived stigma associated withconversations related to obesity and weight management.Figure 1: Role of Adipose Tissue inMaintenance of Body CompositionBrainMuscleLiverEnergy ExpenditureEnergy Distributionand StorageAdrenals,GonadsSummer 2013Appetite,Energy ExpenditureThermogenesis,Energy StorageAdiposeFertility,Energy StoragePancreasEnergy StorageNutrientAbsorptionIntestine6

The first recommendation is to use objective data which“diet.” It is important, however, to be clear with the patientmay include a review the patient’s weight, height, and BMIabout the their clinical numbers, weight classification, andin comparison to that of the normal weight ranges for theassociated health risks. In many cases, patients may notpatient’s weight and height. Indicating where the patientbe aware that they are overweight or obese and, thus, theranks on a BMI chart may also help to depersonalize theNPs may be the first health care provider to inform them.conversation. Clinicians can approach weight much likeTable 3 provides guidance on assessing eating disorders inthey approach other objective data such as blood glucoseoverweight patients.or cholesterol and the patient’s targeted goals. AnotherNext, emphasize why obesity is a health problem —recommended strategy is to avoid using language associatedincluding the signs and symptoms as well as health outcomeswith negative emotions, insensitivity, or negative judgment.such as the minor complaints of shortness of breath whenResearch has shown that patients may perceive specificwalking or difficulty bending over to the more seriouslanguage, including using words such as “overweight”,comorbidities such as heart disease or diabetes. Inform“healthy weight” and “BMI” as non-judgmental and/orpatients that it is your concern that they may develop thesemotivational while other terms such as “fat” and “obese”obesity-related diseases as the rationale for discussing theirmay be perceived as negative (Gray et al., 2011).weight and weight management strategies.Additionally, clinicians might use “physical activity”The second recommendation includes an assessmentinstead of “exercise” and “better nutrition” instead ofof the patient’s motivation and readiness for weight loss.Table 3: Screening for an Eating DisorderEating disorders, particularly binge eating disorder, may complicate the treatment of obesity.Screening for eating disorders can include asking the following questions: Do you eat a large amount of food in a short period of time —like eating more food than another person may eat in, say, a two-hour period of time? Do you ever feel like you can't stop eating even after you feel full? When you overeat, what do you do? (e.g., Have you ever tried to "get rid of" the extra calories thatyou've eaten by doing something like: Take laxatives? Take diuretics [or water pills]? Smoke cigarettes?Take street drugs like cocaine or methamphetamine? Make yourself sick [induce vomiting])?If the patient answers "yes" to any of the above questions, consider further evaluation ora referral to a dietitian or a behavioral health specialist who specializes in eating disorders orin health psychology and working with bariatric patients.More comprehensive screening tools include the SCOFF Questionnaire, or Eating Attitudes Test (EAT-24).Source: Institute for Clinical Systems Improvement (ICSI). Prevention and management of obesity (mature adolescents and adults).Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2011 Apr. 98Summer 20137

Questions that may be helpful in assessing motivation andAn assessment of the community-based or professionalbarriers may include questions related to the patient’s 1)resources available to patients may be helpful in assistingprevious experiences with weight loss; 2) past reasons andthe patient and improving weight management outcomes.goals for previous weight loss efforts; 3) perceived, or actual,Patients may benefit from recommendations of specificsocial and economic support; 4) expectations from familyresources, diets, and physical goals. Evidence supports theand friends; and 5) realistic estimates of the time availableuse of daily food and activity diaries to improve weight lossfor weight loss, particularly for attention to a healthier dietoutcomes which can be then be reviewed with the patient atand increased physical activity.subsequent office visits. Patients and health care providersMotivating the Patientmay sometimes have different perceptions about whetherInitially, patients might not be ready to lose weight andmay require that ongoing assessment and support. The NPmight need to have discussions about the importance ofweight loss at more than one visit, while being sensitive tothe patient’s readiness and/or ability to change. A number ofstrategies, however, can facilitate patient motivation.One recommended strategy is to facilitate the patient inidentifying at least one compelling and personal reason tolose weight. Common examples of patient-centered reasonsinclude: 1) decreasing the risk of a complicated pregnancy;2) being able to keep up with or play with children orgrandchildren; 3) walking without losing one’s breath; or4) preventing further chronic diseases. Some patients mayweight and related behaviors such physical activity and dietwere discussed at routine office visits. One study of 456patients and 30 physicians who were surveyed after officevisits found that patients and physicians were in agreementabout whether or not the topics of weight, physical activity,and diet were discussed for only 61% of office visits(Greiner et al., 2008). Agreement between the providerand the patients was slightly greater for discussions aboutweight than for discussions about diet or physical activity.The researchers concluded that physicians [and other healthcare providers] could improve the care of obese patients byfocusing on specific details for diet and physical activityand, finally, by clarifying that patients perceive that weightrelated information has been shared during the office visithave stronger motivators, including not wanting to become(Greiner et al., 2008).diabetic, or not becoming a burden to their spouses orAdult NonpharmacologicalTreatmentschildren by becoming ill. In the panelists’ experiences, manypatients simply want to know about the health consequencesof obesity. If the NP can provide this information in a nonNonpharmacological strategies for the treatment of adultsensationalized manner, it is often enough to motivateobesity fall within three broad categories: individual-levelweight loss.behavior modification; community-level interventionsSummer 20138

and resources; and local, state, and national policy-levelbound. In using the example of walking three times a weekinterventions.for 30 minutes, the goal should have a specific start andIn the clinical setting, individual-level behavioralend date, perhaps with set sub-goals along the way. Sub-changes for the treatment of obesity generally focus ongoals may include increasing the amount of time spent, orrecommendations of reduced caloric intake and increasedthe intensity of the activity level, by small increments eachphysical activity. Diet and physical activity goals must beweek.customized for each patient, and the panelists are strongadvocates of SMART goal setting: specific, measurable,achievable, relevant, and time-bound goals. (Locke &Latham, 1990). Specific goals that are not vague and thatallow the patient to know when he or she has completedthem. Advising the patient to “get in shape” is a vaguebehavioral goal whereas advising the patient to “walk threetimes a week” is more specific behavioral goal. Measurablegoals facilitate specific goals by setting specific numbers tothe goal so that the patient may then set a specific goal towalk briskly three times a week for 30 minutes. Achievablegoals prevent patients from being discouraged by pursuinggoals that are too ambitious. Depending on previous exerciseexperience, comorbidities and current physical fitness, amore appropriate starting goal might be a recommendationto walk at a moderate pace three times a week for 20minutes as opposed to walking for 30 minutes at a briskpace every day. Goals that are relevant may improve thepatient’s commitment to the goal. Patients need to have areason to set and participate in a physical activity goal threetimes a week other than the sole objective of weight loss.For example, improvements in psychological health, painmanagement, sleep quality or functional capacity may bemore relevant to the patient. Finally, goals should be timeSummer 2013The use of SMART goals provides NPs a foundationfrom which to establish patient-centered strategies tailoredto individual behavior modification. Examples of SMARTgoals for dietary-specific goals include recommendationsof five servings of fruits and vegetables a day, avoidinghigh-calorie or sugar containing drinks, portion control,and limiting meals not prepared at home. See the resourcesappendix for sources of information about diet and physicalactivity. A patient should be evaluated by his or her primarycare provider prior to starting an exercise regimen and seenby a cardiologist if comorbid conditions exist.A similar evidence based approach to behavior change isthe 5 A’s. The 5 A’s heuristic (Ask, Assess willingness tochange, Advise, Assist, and Arrange follow-up) has beenproposed as a general approach to brief health behavioradvice. The five components include (1) Ask—the providerinquires about a patient’s current health behaviors, (2)Assess—evaluation of the patient’s readiness to change,(3) Advise—information giving, such as a risk/benefit ordisease-related advice, (4) Assist—an offer to help with ahealth behavior change, including goal setting or a referral,and 5) Arrange follow up—discussion of a follow-up dateor time frame to assess progress and reassess goals.9

Table 4: Evidence-based Nutritional Interventions:What Works Self-selected diet Dietitian involvement if possible Diet diary Set daily caloric restriction Portion control Breakfast Meal replacements Diet prescriptions Patient handouts Community and internet resources Sample mealsTable 4 summarizes evidence-based interventions that areuseful in individual-level behavioral modification.Another evidence-based approach to behavior change is Recommend self-help books List of allied professionals- Dietitians- Psychologists- Exercise trainersdepend on how it is used as a framework for interventionand in combination with other strategies, particularly dietand physical activities (Tuah et al., 2011).the Stages of Change (SOC) model, which is fundamentalSuccessful weight management requires an incrementalto the Transtheoretical Model (TTM) of behavior approach that integrates physical activity, nutrition,In the TTM SOC, an individual’s readiness and reasons forbehavioral management, and attention to psychosocialchange are assessed and incremental steps from unhealthyneeds. Regular physical activity — ideally 30 to 60 minutesbehavior to healthy ones are adopted (DiClemente,of moderate physical activity on most days a week — isProchaska, & Gibertini, 1985). Although TTM has beenrecommended. However, those higher amounts of activityshown to be a successful approach in smoking reduction(i.e., at least 275 minutes a week) might be requiredamongst adults, its effectiveness for producing behavioralfor weight maintenance among those who have lost achange related to weight reduction in obesity has beenconsiderable amount of weight. Variety and enjoymentmixed (Velicer, Prochaska, Fava, Norman, & Redding,of physical activity are also key features of adherence.1998). A 2011 Cochrane review examined the effectiveness(Meriwether, Lee, Lafleur, & Wiseman, 2008)of dietary and physical activity interventions based onFinally, obesity is a complex, multifactorial, chronicTTM to produce sustainable weight loss in overweight anddisease, with behavioral, biological, and environmentalobese adults (Tuah et al., 2011). This analysis showed thatcomponents. The panelists recommend treating patientsTTM SOC and a combination of physical activity, diet, andas individuals and avoiding one-size-fits-all treatmentother interventions resulted in minimal weight loss, andstrategies. NPs must balance patient centered care with thethere was no conclusive evidence for sustainable weighttranslation and implementation of best practice guidelinesloss. The authors concluded that the impact of TTM SOCand research to improve obesity management outcomes foras theoretical framework in weight loss management maypatientsSummer 201310

Community-level InterventionsCommunity-level programs are important componentsof treating obesity. These types of programs transcendindividual nutrition and exercise goals by supportingcommunities with an infrastructure in which to achieveindividual and community level weight loss goals. Examplesof infrastructure community-based support includes bicycleand running paths, open green spaces, recreation centers,and accessible farmers’ markets.The availability of farmers’ markets, specifically, hasbeen correlated with lower BMI as shown in a recentanalysis from Practice Fusion (2012), a San Franciscobased electronic medical record company. Practice Fusionconducted a retrospective BMI analysis on 72,000 deidentified medical records from a national sample of adultpatients over the age of 18 years and found that based ontheir analysis, Vermont was identified as the healthiest state,where high fruit consumption and abundant farmers’ marketshave kept the statewide BMI in the normal range. Data fromstates such as Oklahoma, Tennessee, and Georgia, wherefarmers’ markets are scarce, revealed a significantly higherprevalence of obesity as measured by BMI (Practice Fusion,2012). A study by Jilcott et al. (2011) of youth in easternadvocates their use with overweight or obese patients, mayfind that these resources serve excellent adjuvant support toassist patients with their weight loss efforts. Smart phoneapps and online directories of parks, playgrounds, and openspaces are available, for instance through the Let’s Move( website. Community-minded NPs,with the help of motivated patients, can work with localgovernment officials and other community leaders to createsafe, open green spaces and farmers’ markets in communitieswhere they are lacking.Public PolicyLocal issues such as parks and farmers’ markets cansometimes lead to larger public policy initiatives thatmay have far-reaching effects on overweight and obesity.For instance, New York City mayor Michael Bloomberghas gained both political friends and foes from enacting anumber of public policy changes which have included aban on smoking in restaurants and bars, a city-wide ban onhydrogenated (or trans) fats in commercially prepared food,and a proposed ban on so-called “super size” sodas. Thetrans fat ban, implemented in 2007-2008, is a particularlyinteresting case study.North Carolina found a similar association between lowerNew York’s trans fat ban was implemented in two phases:BMI and the availability of farmers’ markets (and, in thisthe first required the elimination of trans fats in spreadsstudy, a positive correlation between proximity to fast foodand products used for frying unless the product containedand BMI).less than 0.5 g of trans fat per serving; and the secondThe NP familiar with just a few community resources suchphase required that food products contain any shortening,as farmers’ markets, running/bicycle paths, etc. and whommargarine, or partially hydrogenated vegetable oil with moreSummer 201311

than 0.5 g of trans fat per serving were banned (Lichtenstein,work focuses on informing decision makers in the public2012). A study by Angell et al. (2012), found that the banand private sectors on possible pathways forward. Thewas successful in decreasing consumption of hydrogenatedAlliance’s work is grounded in a set of core principles thatfats. In their study, customers from 168 restaurant locationsserve as the foundation for its research and recommendations.of 11 chains were studied by matching their purchaseAdditionally, the Advocacy Resource Guide Be Our Voice:receipts with available nutritional information and briefMobilizing Healthcare Professionals in the Fight Againstsurveys of adult lunch-time customers pre-ban (2007) andChildhood Obesity ( (2009) purchases. In total, 6969 purchases in 2007index.html) is designed to assist healthcare pr

loss counseling: Female physicians were more likely to recommend weight loss to overweight/obese patients, more frequently provide weight loss counseling, and were more likely to refer patients to a weight loss program than male physicians (Dutton et al., in press). NPs who are overweight themselves might talk about their own experiences with