Nutrition counseling appears in many forms, from dietary advice during a physician visit to medical nutrition therapy (MNT) for diabetes or renal disease. Available U.S. figures show that counseling is not distributed evenly: rates differ by age, obesity status, diagnosis, physician, and insurance program. The measures below cover 2001/2002 through 2019, with the geography stated as the United States unless a source describes a specific program or population.
Contents
- National counseling benchmarks
- Who receives dietary and weight-loss advice
- Primary care counseling patterns
- What obesity visits document
- Arthritis, overweight, and obesity counseling
- Coverage and medical nutrition therapy
National counseling benchmarks
Healthy People 2030’s NWS-05 measure tracks the national status of adult obesity-related counseling. The national status was 21.0% in 2019, compared with a baseline of 24.8% in 2016. The national target is 32.6%. These are status and target figures for the measure; they should not be read as a count of counseling sessions or as a direct estimate of all nutrition counseling.
The 2019 status is 3.8 percentage points below the 2016 baseline, while the target is 11.6 percentage points above the 2019 status. Those differences are simple comparisons of the reported percentages, not a claim about a trend between the measured years. The source is [Healthy People 2030 NWS-05].
An earlier CDC measure provides a broader clinical-visit benchmark. In 2014, 49.7% of adults who had a doctor visit during the previous 12 months received dietary advice. The denominator is adults with a recent doctor visit, not all adults, and the statistic describes advice received during that 12-month period. The source is [CDC MMWR QuickStats 2014].
The measures use different definitions and years. NWS-05 reports a national status for adult obesity-related counseling in 2019, while the CDC QuickStats figure covers dietary advice among adults with a doctor visit in 2014. Comparing them directly would blur those differences in population, counseling definition, and measurement period.
Who receives dietary and weight-loss advice
Age differences were visible among adults with obesity in the 2014 CDC QuickStats data. Among those who had a doctor visit in the previous 12 months, 54.6% of adults with obesity ages 45–64 received dietary advice. The corresponding share was 47.1% among adults ages 18–44 and 47.9% among adults ages 65 and older. These three figures describe age groups within the obesity population; they are not percentages of all adults in those age ranges.
Another U.S. study examined advice reported by obese adults who visited a physician during the previous 12 months. In that population, 39.0% were advised to lose weight. Among the adults who received weight-loss advice, 64.2% were told to change their diet, 85.7% were told to increase physical activity, and 58.5% were told to use both diet and physical-activity strategies. The source is [Weight Loss Advice U.S. Obese Adults Receive from Health Care Professionals].
The same study reported a mean advised weight loss equal to 20.9% of total body weight. This is the mean amount advised among the study population described by that source, not a recommended target for every person with obesity and not a measure of weight actually lost. The diet and activity percentages also use the subset advised to lose weight, so they should not be interpreted as shares of all obese adults.
Together, the figures distinguish three steps that are often combined in casual reporting: having a physician visit, being advised to lose weight, and receiving specific diet or activity advice. A person can be included in the recent-visit population without receiving weight-loss advice, and a person advised to lose weight can receive one or both types of strategy advice.
Primary care counseling patterns
A study of U.S. primary care visits in 2003/2004 found that about 20% included diet or nutrition counseling. About 14% included exercise counseling, about 6% included weight-loss counseling, and about 24% included at least one of those three counseling types. The source is [McAlpine & Wilson 2007]. Because the values are described as “about,” they are approximate study results rather than exact counts.
The same research reported lower odds of receiving any obesity-related counseling in later survey periods than in 1995/1996. The odds were 22% lower in 2001/2002 and 18% lower in 2003/2004 than in 1995/1996. These are relative odds comparisons, not percentage-point declines in the share of visits receiving counseling.
Counseling was also concentrated among a small group of physicians in a 2007–2008 NAMCS study. The study analyzed 21,220 adult outpatient primary care visits and included 954 primary care physicians. Fifty-eight percent of primary care physicians performed no weight counseling during any patient visits in the study. Meanwhile, 8.9% of physicians accounted for 52% of all weight counseling.
The study identified “positive-deviance physicians” with an adjusted odds ratio of 13.2 for counseling compared with other physicians. An adjusted odds ratio expresses a modeled relative association after adjustment in the study; it does not mean that 13.2 times as many patients definitely received counseling. The source is [The Epidemiology of Weight Counseling for Adults in the United States].
These primary care findings point to variation at the clinician level as well as the patient level. The 2003/2004 visit measures describe whether counseling types appeared during visits, while the 2007–2008 physician analysis describes how counseling was distributed across clinicians. They answer related but different questions.
What obesity visits document
CDC NCHS Data Brief 237 compared U.S. obesity visits with visits for other diagnoses in 2012. Height and weight were both recorded in 78% of obesity visits, compared with 58% of visits for other diagnoses. Blood pressure was recorded in 92% of obesity visits and 69% of other-diagnosis visits.
At least one weight-related service was listed in 40% of obesity visits, versus 9% of visits for other diagnoses. Specific education services were recorded at these rates:
| Documented service in 2012 | Obesity visits | Visits for other diagnoses |
|---|---|---|
| Diet and nutrition education | 33% | 6% |
| Exercise education | 24% | 5% |
| Weight-reduction education | 26% | 2% |
The comparison shows that documentation of diet and nutrition education was more common in obesity visits, but it was not present in every such visit. It also shows why “a weight-related service” should not be treated as synonymous with nutrition counseling: the combined service measure includes more than one type of intervention, while diet and nutrition education is a separate category.
The 2012 brief also reported additional chronic conditions. At least one additional chronic condition was listed in 73% of obesity visits, compared with 56% of other-diagnosis visits. Hypertension appeared in 42% of obesity visits and 32% of other-diagnosis visits. Hyperlipidemia appeared in 27% and 20%, respectively; diabetes in 29% and 19%; and depression in 20% and 12%.
These figures describe items listed during visits, not necessarily newly diagnosed conditions, completed counseling sessions, or the quality of advice. They also come from 2012, so they should not be presented as current utilization rates.
Arthritis, overweight, and obesity counseling
CDC MMWR 2018 reported a rise in health care provider counseling for weight loss among U.S. adults with arthritis and overweight or obesity. The rate increased from 35.1% in 2002 to 45.5% in 2014, a reported increase of 10.4 percentage points. The 2014 rate met the Healthy People 2020 target of 45.3%.
The population size also changed across the measured years. Among adults with arthritis and overweight or obesity, 28.3 million had those conditions in 2002, compared with 38.9 million in 2014. These are population estimates reported by the CDC source; the change in the number of people should not be used to calculate an unsupported counseling count.
Counseling rates varied substantially by weight category:
| Group with arthritis | 2002 | 2014 |
|---|---|---|
| Overweight | 18.1% | 23.8% |
| Obesity | 50.4% | 62.8% |
| Class 1 obesity | 40.8% | 52.6% |
| Class 3 obesity | 69.0% | 84.5% |
The categories are not interchangeable. The overall arthritis-plus-overweight/obesity rates and the subgroup rates use the definitions reported by CDC MMWR 2018. In particular, class 1 and class 3 obesity are subgroups of obesity, while the overweight row is separate. The higher rate for class 3 obesity does not establish that counseling caused weight change or that severity alone determined whether counseling occurred.
Coverage and medical nutrition therapy
Medicare’s MNT coverage rules provide a defined amount of covered nutrition care for certain beneficiaries. Under CMS NCD 180.1, Medicare covers 3 hours of MNT during the first year for beneficiaries with diabetes or renal disease, effective January 1, 2022. Subsequent-year coverage is 2 hours for beneficiaries with diabetes or renal disease. Version 2 of the MNT national coverage determination became effective January 1, 2022 and was implemented July 5, 2022.
These hour limits describe covered MNT under the specified Medicare policy; they are not a measure of how many hours every eligible beneficiary uses or of counseling supplied by every nutrition professional. Eligibility and coverage context matter when interpreting them.
CMS also reported that 28% of Medicare beneficiaries had diabetes and 15% had chronic kidney disease in the source labeled [CMS National Nutrition Month 2013]. The source also said that more than 35% of American men and women were obese. Those figures are legacy facts from that CMS publication and should not be treated as independently verified or as current prevalence estimates.
Medicaid and CHIP coverage varied by state in a CMS review of 2008 policies. Ten states provided evidence of coverage for nutritional and/or behavioral therapy for children. Thirty states plus the District of Columbia provided some, but inconclusive, evidence of coverage. Ten states did not address reimbursement of nutritional assessment or behavioral therapy in their manuals. The review also said Medicaid and CHIP provided coverage for approximately 60 million people.
The CMS report noted that Medicaid state manuals listed licensed nutritionists as providers who could deliver diet and nutrition assessment and counseling. The state-policy figures describe what the 2008 review found in manuals and evidence of coverage; they do not establish uniform national access, current reimbursement, or the number of counseling visits delivered.