Family physicians’ perception on environmental influences in promoting physical activity in their obese patients


Although many obese patients do not engage in adequate physical activity (PA), little is known about whether physicians discuss environmental barriers in promoting PA. We conducted this study to describe physicians’ views about discussing environmental barriers in promoting PA with obese patients and determine whether counseling varies by years of practice. We conducted an online survey of family physicians practicing in 17 clinics in Central Texas. We performed descriptive analysis on barriers to PA, counseling on meeting PA recommendation, and written prescription for exercise and bivariate analysis by years of practice. Statistical significance was set at p < 0.05. Of 96 physicians invited, 57 (59.4%) completed the survey. Majority reported their obese patients brought up the environment as a barrier to walking (89.3%) or PA (91.2%). Majority (80.7%) also reported asking about environmental barriers to walking, with 84.2% giving specific examples to overcome these barriers. While 96.5% reported advising their obese patients about meeting the PA recommendation, only 26.3% reported giving them a written prescription for exercise. These did not vary significantly by years of practice. Physicians felt having more time with their patients and knowing specific strategies to overcome environmental barriers, safe places in patients’ neighborhoods, and what environmental factors influence PA may help discuss environmental issues with their obese patients. Physicians want and counsel their obese patients to be physically active, but do not generally give prescriptions for exercise irrespective of years of practice. They also want tools to enhance their abilities to better assist these patients.

Share and Cite:

Forjuoh, S. , Lee, C. , Wang, S. , Hong, Y. and Ory, M. (2012) Family physicians’ perception on environmental influences in promoting physical activity in their obese patients. Open Journal of Preventive Medicine, 2, 423-428. doi: 10.4236/ojpm.2012.24060.


Obesity is a growing health problem worldwide. It affects Americans of all ages across the entire nation [1]. Current estimates indicate that almost a third of adult Americans are obese [2], with rates disproportionately high among certain minority and ethnic groups and those characterized by lower socioeconomic status [3]. Although moderate exercise such as walking can help prevent or manage health problems associated with obesity [4], many obese individuals do not engage in adequate physical activity [5]. Currently, less than half of American adults are estimated to obtain the recommended physical activity level of a minimum of 30 minutes of physical activity daily for at least five days per week [3]. A 2003 US Physical Activity Study found that nationally only 34% of the population were regular walkers who met the recommended physical activity level, 46% were occasional walkers, and 21% were not walking at all [6]. These statistics mirror data on physician counseling of their patients about exercise, which is low nationally at an estimated 30% - 40% depending on assessment methodologies and populations being examined [7-9].

The physical environment may have a major influence on physical activity by acting both as a barrier and as a facilitator [10]. In particular, forms (e.g., sidewalks and street network patterns), uses (e.g., shops and recreational facilities) and the characteristics (e.g., safety and lighting) of the built environment can influence physical activity, especially walking [11,12]. Getting injured due to an environmental hazard may limit one’s desire to engage in physical activities, for example, fracturing a limb from a fall. Similarly getting mugged due to lack of adequate lighting in one’s environment may severely limit one’s desire to go out for a walk. While environmental interventions may not necessarily enhance physical activity for everyone, they may be particularly effective for certain segments of the population such as those who are less healthy, unemployed, or retired [13]. Further, environmental inequities have been linked to health disparities related to obesity and diabetes [14].

Healthcare providers have a role in promoting physical activity. Physicians generally recommend increasing physical activity to patients, albeit less so to their overweight and obese patients [15]. Among the reasons cited by physicians for counseling only a minority of patients include time constraints, lack of resources to effect behavioral changes, lack of reimbursement, limited training in appropriate behavioral change counseling, and perceived lack of interest from patients [9]. In hopes of contributing to the development of best practice tools for use by physicians to counsel their patients to help overcome environmental barriers to physical activity, we designed this study to examine the extent to which primary care physicians encourage walking and other physical activity to their patients, and are aware of and address environmental facilitators or barriers.


2.1. Study Design and Setting

Working in collaboration with the Central Texas Primary Care Research Network (CenTexNet), a primary care Practice-Based Research Network (PBRN) based in Temple, Texas, we conducted a cross-sectional on-line survey using the website of the Agency for Healthcare Research and Quality’s PBRN Resource Center. The study setting was 17 primary care clinics of a large university-affiliated, multi-specialty group practice associated with a 250,000-member health maintenance organization in Central Texas. All the clinics were affiliated with CenTexNet and were staffed by a total of 100 family physicians. The study was conducted from October of 2008 through January of 2009. Both the Scott & White Healthcare and the Texas A&M University Institutional Review Boards reviewed and approved the study protocol. No written informed consent was sought from subjects for study participation.

2.2. Study Subjects

Study subjects were all family physicians practicing in the 17 primary care clinics, who were all members of CenTexNet. They were enrolled voluntarily and provided a link to the PBRN Resource Center website to access the survey via e-mail.

2.3. Data Collection Tools

To inform the development of our survey instrument, we visited with our network physicians during one of their monthly meetings to solicit their ideas and opinions on areas of particular interest to them regarding obesity, physical activity, and the physical environment. We also discussed their awareness of environmental barriers that might affect their recommendations for increasing physical activity, as well as the survey formatting and length. Based on the visit, the survey instrument was designed to obtain data on: 1) physicians’ opinions about physical activity and neighborhood environments; 2) physicians’ interactions with their typical obese patients regarding physical activity during their last few clinic encounters; 3) their assessments of obese patients’ engagement in physical activity and walking specifically; 4) physicians’ likelihood of bringing up environmental issues and concerns related to physical activity and walking during clinic encounters with their obese patients; 5) physicians’ perceptions about environmental barriers to physical activity and walking for obese patients; 6) physicians’ perceptions about good walking environments for obese patients; and 7) physicians’ own physical activity behaviors and practices.

The final survey instrument included ordinal-scale questions such as “Strongly agree to strongly disagree” (4 items), “Often-Sometimes-Never” (3 items), and “Very important-Somewhat important-Not at all important” (3 items), “Yes-No” (2 items), and open-ended questions, along with questions on basic demographic data. No individually identifiable information such as name and age was collected. A copy of the contents of the survey can be obtained from the lead author.

2.4. Statistical Analysis

Data management and analysis were performed using SPSS version 17. We first compared the respondents and non-respondents using the chi-square statistic. We then performed descriptive analysis on barriers to PA, counseling on meeting PA recommendation, and written prescription for exercise and bivariate analysis by years of practice. Statistical significance was set at p < 0.05. Given the small sample size and lack of adequate descriptive information about the physicians, we were not able to perform more multivariate analyses.


3.1. Survey Response Rates

Of all the 100 physicians initially invited to participate in the study, four were deemed ineligible due to one respondent being on maternity leave, one leaving their practice, one not providing continuity care, and one being a dietician. Of the 96 eligible physicians, 57 completed the survey resulting in a 59.4% response rate. Respondents were similar to non-respondents by gender, with 70.2% of respondents being male versus 71.8% of non-respondents (p = 0.95).

3.2. Physician Characteristics

Table 1 shows the characteristics of the final study

Conflicts of Interest

The authors declare no conflicts of interest.


[1] US Department of Health and Human Services (2008) Physical activity guidelines for Americans 2008.
[2] Flegal, K.M., Carroll, M.D., Ogden, C.L. and Curtin, L.R. (2010) Prevalence and trends in obesity among US adults, 1999-2008. Journal of the American Medical Association, 303, 235-241. doi:10.1001/jama.2009.2014
[3] CDC (2009) Prevalence and trends data. Report No. 2011.
[4] US Department of Health and Human Services (2010) The surgeon general’s vision for a healthy and fit nation. Public Health Reports, 125, 514-515.
[5] Rejeski, W.J., Brubaker, P.H., Goff, D.C. Jr., Bearon, L.B., McClelland, J.W., Perri, M.G. and Ambrosius, W.T. (2011) Translating weight loss and physical activity programs into the community to preserve mobility in older, obese adults in poor cardiovascular health. Archives of Internal Medicine, 171, 880-886. doi:10.1001/archinternmed.2010.522
[6] Eyler, A.A., Bronson, R.C., Bacak, S.J. and Houseman, R.A. (2003) The epidemiology of walking for physical activity in the United States. Medicine & Science in Sports & Exercise, 35, 1529-1536. doi:10.1249/01.MSS.0000084622.39122.0C
[7] Anis, N.A., Lee, R.E., Ellerbeck, E.F., Nazir, N., Greiner, K.A. and Ahluwalia, J.S. (2004) Direct observation of physician counseling on dietary habits and exercise: Patient, physician, and office correlates. Preventive Medicine, 38, 198-202. doi:10.1016/j.ypmed.2003.09.046
[8] Ma, J., Urizar, G.G. Jr., Alehegn, T. and Stafford, R.S. (2004) Diet and physical activity counseling during ambulatory care visits in the United States. Preventive Medicine, 39, 815-822. doi:10.1016/j.ypmed.2004.03.006
[9] Ory, M.G., Peck, B.M., Browning, C. and Forjuoh, S.N. (2007) Lifestyle discussions during doctor-older patient interactions: The role of time in the medical encounter. Medscape General Medicine, 9, 48.
[10] Santariano, W., Ory, M. and Lee, C. (2012) Planned and built environments: Interactions with aging. Public Health in an Aging Society, The Johns Hopkins Press, Baltimore, In Press.
[11] Lee, C. (2007) Environment and active living: The roles of health risk and economic factors. American Journal of Health Promotion, 21, 293-304. doi:10.4278/0890-1171-21.4s.293
[12] Lee, I.M. and Buchner, D.M. (2008) The importance of walking to public health. Medicine & Science in Sports & Exercise, 40, S512-518. doi:10.1249/MSS.0b013e31817c65d0
[13] Forsyth, A., Brownson, R.C. and Day, K. (2009) The built environment, walking and physical activity: Is the environment more important to some people than others? Transportation Research Part D: Transport and Environment, 14, 42-49. doi:10.1016/j.trd.2008.10.003
[14] Popkin, B.M., Duffey, K. and Gordon-Larsen, P. (2005) Environmental influences on food choices, physical activity and energy balance. Physiology & Behavior, 86, 603-613. doi:10.1016/j.physbeh.2005.08.051
[15] Phelan, S., Nallari, M., Darroch, F.E. and Wing, R.R. (2009) What do physician recommend to their overweight and obese patients? Journal of the American Board of Family Medicine, 22, 115-122. doi:10.3122/jabfm.2009.02.080081
[16] Forjuoh, S.N., Lee, C., Wang, S., Hong, Y. and Ory, M.G. (2011) Patient-physician discussion of physical activity and environmental barriers. Preventive Medicine, 53, 209- 210. doi:10.1016/j.ypmed.2011.07.010
[17] (1998) Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults— The evidence report. National Institutes of Health. Obesity Research, 6, 51S-209S.
[18] Glasgow, R.E., Emont, S. and Miller, D.C. (2006) Assessing delivery of the five “As” for patient-centered counseling. Health Promotion International, 21, 245-55. doi:10.1093/heapro/dal017
[19] Cress, M.E., Buchner, D.M., Prochaska, T., et al. (2005) Best practices for physical activity programs and behavior counseling in older adult populations. Journal of Aging and Physical Activity, 13, 61-74.
[20] VanGeest, J.B., Johnson, T.P. and Welch, V.L. (2007) Methodologies for improving response rates in surveys of physicians: A systematic review. Evaluation & the Health Professions, 30, 303-321. doi:10.1177/0163278707307899

Copyright © 2024 by authors and Scientific Research Publishing Inc.

Creative Commons License

This work and the related PDF file are licensed under a Creative Commons Attribution 4.0 International License.