Integration of the 5A’s Framework in Research on Obesity and Weight Counseling: Systematic Review of Literature

Abstract

The 5A’s Framework (Assess, Advise, Assist, Agree, and Arrange) has been recommended as a practice guide for obesity counseling. Its integration in research, however, is not well known. This systematic review was to find how the 5A’s Framework was integrated in research on obesity and weight counseling. Methods: A systematic search of four databases was conducted combining two concepts: “5 A’s Framework” and “obesity, body size, dieting/eating, exercise, weight loss.” Inclusion criteria were quantitative studies with the 5A’s Framework as a singular intervention or combined with others to influence patients’ healthy eating, physical activity, and weight outcomes or care providers’ counseling behaviors. Twenty-two studies were included in the final analysis. Results: Most studies were conducted in the primary care setting. The 5A’s Framework was (1) integrated in training interventions as formal medical curricular and on-the-job education workshops to influence obesity/weight counseling skills, (2) utilized to develop assessment tools to evaluate counseling behaviors, and (3) combined with behavior change strategies to impact the patient’s weight management behaviors and outcomes. Conclusion: The integration of the 5A’s Framework in obesity and weight counseling research is wide-ranging. The findings have implications for clinicians to use the framework to better obesity/weight counseling.

“A unique contribution of our systematic review is the assessment of the 5A’s Framework intervention details using the TIDieR checklist.”

Nearly 60% of adults are overweight or obese worldwide, which affects 2.5 billion people. ¹ Obesity places people at risk for cardiovascular disease, metabolic disease, cancer, clinical depression, and poor health-related quality of life.^2,3 Overweight and obesity can be affected by lifestyle behaviors such as eating and physical activity. ⁴ Adults who engage in healthy lifestyle behaviors are more likely to control their weight and postpone the onset of developing chronic diseases for up to 9 years than those who do not regularly engage in healthy behaviors. ⁵ To achieve a healthy lifestyle, individuals can initiate action plans and maintain healthy behaviors. However, many people may lack knowledge, skills, and recourses to execute healthy eating and physical activity; subsequently, they need counseling and support from health professionals.

The US Preventive Services Task Force recommends clinicians offer or refer adults with a body mass index (BMI) of 30 or higher to intensive behavioral interventions. ⁶ The American Academy of Family Physicians’ clinical guidance for obesity and healthy lifestyle suggests that clinicians provide counseling and help patients identify obstacles to healthy eating, set realistic goals for physical activity, and develop behavioral strategies. ⁷ It is noted that lifestyle behavioral counseling is also beneficial for people whose body weight falls in the overweight category (BMI = 25-29.9) or those who have lost weight and want to prevent weight regain. Given the need for behavioral interventions and recommendations for obesity counseling, it is imperative for clinicians to know how to provide the obesity and weight counseling.

One intervention for addressing obesity and weight counseling is the 5A’s Framework. ⁸ The 5A’s Framework was developed by the National Cancer Institute to guide clinicians in addressing tobacco smoking cessation. ⁹ The 5’As Framework was later repurposed for weight counseling.^10,11 In 2012, the Canadian Obesity Network supported the delivery of 5A’s weight counseling in family medicine practices. ¹² Generally, various iterations of the 5A’s Framework have included five of the following components: (1) Asking (with objective measurement and assessment), (2) Advising (concerning the need for and benefits of achieving a desired outcome), (3) Assessing (patient readiness to change lifestyle behavior), (4) Agreement (between patient and clinician concerning behavior change plan), (5) Assisting (in establishing appropriate intervention or referrals), and (6) Arranging (follow-up on the behavioral change).^13-15

Some researchers suggest that high-intensity obesity counseling should include 12 sessions a year, and the counseling can be given in person, by phone, or electronically. ¹⁶ Others recommend that interactive behavior change technology for 5A’s based interventions be implemented in the primary care setting to structure health care providers’ clinical interactions and maximize their impact on obesity treatment.^17,18 Published systematic reviews that provide intervention details, such as why, how, when, who, and where to implement the 5A’s Framework, is limited. A previous systematic review addressed the 5A’s Framework implemented in clinical setting for individual health behavior change. ¹³ Another systematic review, based on the findings from 15 studies, concluded that during weight loss counseling, patients would like their physicians to Arrange, followed by Advise, Agree and Assist, but physicians most frequently Advised and Assessed. ¹⁴ A third systematic review outlined the definitions of the 5A’s components, the rationale, and sample questions a clinician could ask relevant to each component. ¹⁵ These previous systematic reviews did not shed light on implementation details of the 5A’s Framework in obesity and weight counseling. Evidence-based practice is built on consistent findings from multiple studies. But evidence-based implementation procedures are as important as research outcomes. Evaluating intervention details across studies is valuable for researchers to replicate a study and clinicians to adopt an intervention in practice. The purpose of this systematic review was to assess the integration of the 5A’s Framework, including implementation details, in obesity and weight counseling research that addressed lifestyle behaviors (eating, physical activity) in adults with overweight or obesity.

Methods

We adopted the stages of conducting systematic reviews model by Siddaway et al. ¹⁹ The stages included scoping (formulate research questions), planning (formulate search terms and preliminary inclusion/exclusion criteria), searching (use multiple databases), screening (export references to a citation manager and assess studies for inclusion/exclusion), and presenting results (extract and synthesize data and offer a new, improved understanding of the phenomena).

Scoping

The research question was “how is the 5A’s Framework integrated into research on obesity and weight counseling?”

Planning and Searching

A systematic search of 4 databases was conducted by the health sciences librarian (AJ). We searched PubMed, Embase, CINAHL Complete, and APA PsycINFO combining 2 concepts: “5 A’s Framework” and “obesity-related concepts including: body size/BMI, dieting/eating, exercise, weight loss, etc.” (See Supplement 1 for search strategies). The 5 A’s Framework is referred to counseling techniques/content that include 5 of the following components: ask, advise, assess, agree, assist, and arrange. The inclusion criteria included the publication date range of January 2000 to September 2023. The 5 A’s Framework was recommended by the National Institutes of Health for obesity behavior management in 1998 ²⁰ ; subsequently publications on the 5A’s Framework in obesity/weight counseling began to surge. Additional inclusion criteria were that publications must report quantitative results and include the 5A’s Framework within an intervention to influence the outcomes of adult obesity-related behaviors (weighing, healthy eating, and physical activity) or weight outcomes, and/or clinician counseling behaviors. Exclusion criteria included publications examining smoking, substance use, HIV, or cancer. Additionally, animal studies, case studies, qualitative research, systematic reviews and/or meta-analyses, conference abstracts, and protocols were excluded.

Screening

The initial search found 755 records. Duplicate records were removed using a variation of the EndNote de-duplication method. ²¹ Records were then imported from the reference manager into Covidence for screening, review, and extraction. After removing 227 duplicate records, 40 records were randomly selected (AJ) and used for training the research team (CS, HH, MD). During the training, each record was reviewed by 2 team members against inclusion and exclusion criteria, which resulted in an interrater agreement rate of 80% (2 members had the same screen results). Meetings were held throughout the screening process (training and abstract/full-text reviews) to discuss the records with conflicting review results until a resolution was made either by 2 reviewers achieving an agreement or by the first author making a final decision. The team reviewed abstracts of the remaining 528 records and retained 65 records for full-text review with an agreement rate of 93.75%. Additional records were removed during full-text review, resulting in 22 articles for the final analysis (PRISMA ²² flow diagram in Figure 1).

Figure 1.

PRISMA diagram for literature search and article selection.

Literature Analysis

The TIDieR (Template for Intervention Description and Replication) checklist was used to facilitate analysis and report. ²³ TIDieR includes 12 questions about intervention details, such as brief name of the intervention (study purpose), why (theory/model), what (activity, material), who (intervention provider), how (mode of delivery), where (location of the intervention), when and how much (frequency, length), tailoring (personalized, titrated, adapted), modification (change), and how well (attrition, adherence). Excel files were created, and the first author (CS) and a research assistant independently extracted information from each article to capture TIDieR required information.

Presenting Results

Extracted information was synthesized and presented in tables. We synthesized our results into 4 categories of interventions for: (1) medical students and residents, (2) physicians, (3) non-physician health care providers, and (4) patients. In the results section, we first summarize study purpose, how the 5A’s Framework was used, and the components of the 5A’s Framework across studies. We then report intervention details based the TIDieR checklist.

Study Quality Assessment

We used the National Heart, Lung, and Blood Institute tools for multiple types of studies to appraise study quality because our analysis included studies of various designs. ²⁴ Among the 15 studies with an experimental design and a comparison group, 4 had a quality rating > 70% (% meeting the criteria in the assessment tool). Two of the 5 studies with a pre-post design demonstrated a quality rating of 70%. None of the cross-sectional studies (n = 2) had a quality rating of 70% (see details in Supplement 2).

Results

Study Characteristics

As shown in Table 1, the 22 articles described studies conducted in the U.S. (n = 13), Canada (n = 4) and 5 other countries (Germany, Iran, Mexico, South Africa, and Spain). These articles reported 5A’s interventions for obesity/weight (n = 11), physical activity (n = 7), and combinations of diet, physical activity, and obesity/weight counseling (n = 4). Fifteen studies adopted an experimental design with a control group, but they either included randomization or did not. Other studies demonstrated a pre-post design without a control group (n = 5) or a cross-sectional study design (n = 2).

Table 1.

Study Characteristics (N = 22 Studies).

Author-Year	Country	Study Population	Study Design	Health Issues
Amini 25 -2023	Iran	184 health workers (midwifery and public health; 184 clients aged 30-70	RCT	Nutrition, physical activity, smoking
Campbell-Scherer 26 -2019	Canada	24 teams (nurses, mental health workers, and dietitians) but focused on 32 nurses	RCT	Obesity
Carroll 27 -2014	USA	10 family medicine clinicians; 319 low-income adults	Two-group pragmatic RCT-wait list	Physical activity
Caroll 28 -2016	USA	13 physicians and 325 low-income adults	Pragmatic pilot clinical trial-wait list	Physical activity
Contreras-Martos 29 -2021	Spain	3062 adults aged 45-75	Clustered RCT with an effectiveness-implementation type 2 hybrid design	Physical activity
Costanzo 30 -2006	USA	46 sedentary women aged 50-65	Experimental pre/posttest comparison group design	Physical inactivity
Flocke 31 -2005	USA	8 first-year medical students to collect data of 300 visits by adults aged 18-80	Cross-sectional direct observation	Diet, exercise, weight loss
Galaviz 32 -2017	Mexico	36 primary care physicians; patients aged 18 and older	Effectiveness-implementation type 2 hybrid design with a control group	Physical activity
Iyer 33 -2018	USA	28 primary care residents	Pre and post survey	Obesity
Jay 34 -2010	USA	23 primary care internal medicine residents; 163 patients BMI >30	Non-randomized, wait-list/control design	Obesity
Jay 35 -2013	USA	23 primary care internal medicine residents; 158 patients BMI >30	Wait-list design	Obesity
Krist 36 -2008	USA	48 physicians, residents and others; patients 18 or older	Cross-sectional, measured outcome once	Obesity, tobacco and alcohol use, diet, physical inactivity
Lewis 37 -2017	USA	40 patients aged 55-74; 36 stakeholders (staff/faculty)	Pragmatic, primary care-based intervention using randomization and with a comparison group	Physical activity
Luig 38 -2020	Canada	42 family medicine residents	Multi-methods design without a control group	Obesity
Malan 39 -2016	South Africa	23 primary care doctors and 12 clinical nurses	One-group, before-and-after design	Unhealthy eating, physical inactivity, tobacco/alcohol use
Ockene 40 -2021	USA	915 1st year medical students	Pair-matched, group-RCT	Weight management
Reed 41 -2019	USA	59 rural adults exercising <150 minutes/week	Experimental randomized two-group related measures	Physically inactive
Rueda-Clausen 42 -2014	Canada	25 health care providers; patients BMI >30	One-group quasi-experimental (before and after) design	Obesity
Viglione 43 -2019	USA	45 Veterans BMI>30 or 25-29.9 with comorbidities	RCT	Weight management
Weeks 44 -2020	Canada	11 midwives and 4 obstetricians; 100 pregnant women aged >18	Quasi-experimental study without a control group	Gestational weight gain
Welzel 45 -2021	Germany	50 GPs and 135 adults aged 18-60 with a BMI >30	Cluster-RCT with a waiting list design	Obesity
Wilson 46 -2010	USA	146 patients with overweight	Non-randomized, pre and post design with comparison groups	Overweight and obesity

RCT: Randomized controlled trial.

5A’s Interventions Focused on Medical Students and Medical Residents

Six articles reported 5A’s interventions conducted with medical students (n = 2)^31,40 and internal/family medicine residents (n = 4).^33-35,38 The 6 studies evaluated 5A’s interventions on (1) physician-patient discussion of weight management strategies, (2) competencies or skills of medical students and residents in obesity/weight counseling, (3) attitudes and beliefs about obesity, and (4) weight loss outcomes of the patient due to obesity/weight counseling (Table 2). Researchers included the 5A’s Framework in a formal curriculum or in tools to guide counseling skills. The 5 A’s components of Assess, Advise, and Assist appeared in all 6 studies, and Arrange, Agree, and Ask were in 5, 4, and 3 studies, respectively.

Table 2.

Study Purpose and 5A’s Based Studies (n = 22).

Author-Year	Study Purpose	How 5A’s Framework Was Used	5A’s and Specific Information
5A’s for medical students and medical residents
Flocke 31 -2005	How the 5A’s heuristic affects physician-patient discussion of exercise, diet, and weight loss and if individuals with a greater BMI or a chronic disease more likely to receive comprehensive advice	5A’s were integrated into an observation checklist for diet, exercise, and weight loss counseling	• Ask: Current health behaviors • Assess: Readiness to change • Advise: Information giving, risk/benefit or disease • Assist: Goal setting or a referral • Arrange: Follow-up date, time frame to assess progress and reassess goals
Iyer 33 -2018	Evaluate obesity counseling competence among residents in a primary care training program	5A’s in the curriculum and in self-assessment tool	• Assess: History, com-morbidities, readiness and ability to change • Advise: Obesity on health and personalized risk, treatment option • Agree: Prescribed plans, setting goals, provide guidance • Assist: Brief counseling, motivational interviewing • Arrange: Effective referral
Jay 34 -2010	Assess the impact of an obesity counseling curriculum for residents on obesity counseling using 5A’s strategies	A 5-hour multi-modal obesity counseling curriculum based on the 5A’s and 5A’s in an assessment tool (basic and advanced skills)	• Assess: Risks, current behavior, readiness to change • Advise: Change of specific behavior • Agree: Collaboratively set goals • Assist: Addressing barriers and securing support • Arrange: Follow-up
Jay 35 -2013	Assess a multi-modal longitudinal obesity curriculum based on the 5A’s associated with weight loss in obese patients	A multi-model longitudinal obesity curriculum based on the 5A’s taught across 3 weeks	• Assess: History, stage of change, current behaviors • Advise: Patient-centered advice • Agree: Collaborating goal setting • Assist: Addressing barriers, motivational interviewing • Arrange: Frequent follow-up, ancillary/community services
Luig 39 -2020	Assess the impact of the 5AsT-MD course on residents’ attitudes, beliefs, and confidence with obesity counseling	The 5A’s approach and tools in lectures, practiced both with standardized patients and clinic patients	• Ask: Permission discuss weight • Assess: Obesity-related risk and root course of weight gain • Advise: Obesity-related complications, treatment options • Agree: Weight loss expectations, sustainable behavior, goals • Assist: Addressing barriers to weight management
Ockene 40 -2021	Assess the effect of a multi-modal weight management curriculum on counseling skills for health behavior change	Counseling focused on the 5A’s intervention in a standardized manner across schools in the intervention group	• Ask: Risks, history of weight management, current diet/PA • Advice: Concerns r/t BMI, benefits of weight loss • Assess: Motivation, commitment, readiness, self-efficacy • Assist: Barriers, goals, change strategies • Arrange: Referral, weight discussion in the next appointment
5A’s for physicians
Carroll 27 -2014	Examine the effectiveness of a 5’A approach to physical activity counseling in a medically underserved patient population	Integrated 5A’s in the training	• Ask: Exercise history, willingness and confidence to change • Advise: Reasons to become physically active • Agree: Negotiate exercise plan • Assist: Turn setback into learning, cope with barriers • Arrange: Community exercise program referral, integrating counseling into visit, future visits
Caroll 28 -2016	Evaluate the effect of a clinician training intervention on physical activity counseling for underserved adults using the 5A’s framework	5A’s in a competency checklist when practicing skills with a standardized patient	• Ask about (or assess) • Advise: Tailoring to the patient, setting goals mentioning resources • Agree: Exploration of patient willingness to engage • Assist: a Goal being set or discussed • Arrange follow-up regarding patients’ behavior change efforts
Galaviz 32 -2017	Evaluate the implementation and effectiveness of a pragmatic strategy using 5A’s to improve physician physical activity (PA) counseling and patient PA	The 5A’s model was used to document the content of discussion of exercise, diet, and weight loss during adult outpatient visits	• Ask: Level of physical activity • Advise: Benefits of increasing physical activity, recommended guidelines, providing a written prescription • Agree: Collaboratively agreeing on a physical activity goal • Assist: Barrier identification and resolution • Arrange: Follow-up using referrals to PA resources in the clinic and community
Krist 36 -2008	Test the feasibility of an electronic linkage system (eLinkS) to help connect these entities to support behavioral counseling	5A’s embedded in the electronic medical record (EMR) to help clinicians systematically perform elements of the 5A’s	• Assess: Screen prompt for staff to enter weight, height and other unhealthy behavior • Address: EMR opens a forum • Advise: Checkboxes to give advice for behavior change • Agree: Ready to improve and engage • Assist: Automate referral to intensive counseling • Arrange: Telephone, appointment, or email for follow-up by the practice
Welzel 45 -2021	Evaluate INTERACT a 5’As online tutorial in improving weight management and provider–patient interaction in primary health care	The 5A’s online tutorial comprises an introduction, five knowledge sections and a short knowledge quiz (7 questions) upon completion	• Ask: Discuss weight and motivation • Assess: Health status, obesity class, comorbidities and causes of weight gain • Advise: Obesity risks, benefits of treatment and available treatment options • Agree: Health outcomes, weight loss expectations, treatment plan • Assist: Continuous process of weight management and follow-up visits
5A’s for non-physical health care providers
Amini 25 -2023	Design, implement, and evaluate a healthy lifestyle counseling training program based on the 5 As model	5A’s used in healthy lifestyle counseling skills training and a checklist and a questionnaire	• Ask: Relevant risk factors • Advise: Provide information, clear, simple and personal • Assess: Readiness for change • Assist: Develop a plan • Arrange: Follow up
Campbell-Scherer 26 -2019	Assess the 5A’s team educational intervention on quantity of obesity visits conducted by family practice nurses	The education intervention built upon the 5A’s of obesity management	• Ask: No mention • Assess: No mention • Advise: No mention • Agree: No mention • Assist: No mention
Malan 39 -2016	Evaluate the effect of the brief behavioral change counseling training integrating 5A’s on clinical practice	The training course integrated 2 behavior change approaches, the 5 A’s and a guiding style derived from motivational interviewing	• Ask: Risky behavior, permission to discuss, patient knowledge • Alert: Provide tailored information, elicit understanding • Assess: Readiness and confidence to change • Assist: Options, autonomy in decisions, relevant practical assistance • Arrange: Follow-up appointment, involve the patient’s social support system such as friends or family
Rueda-Clausen 42 -2014	Evaluate the impact of the 5’As obesity management tool in primary care settings and its impact on weight and health	Standardized training about the 5A’s of obesity management	• Ask: Permission to discuss a patient’s weight and determine, their readiness to change • Assess: Risk, obesity stage and class and current unhealthy behaviors and economical barriers • Advise: Obesity risks and therapeutic alternatives • Agree: Collaboratively set goals • Assist: Accessing the appropriate providers, education resources and arranging follow-up
Weeks 44 -2020	Evaluate the impact of the 5 As tool on patient perceptions of GWG discussions with their HCP and to identify suggestions to improve the tool	The workshop highlighted the importance of GWG communication with their patients and demonstrated the use of the 5A’s tool	• Ask: Nonjudgmentally, for permission to discuss weight • Assess: Pre-pregnancy BMI and pregnancy weight gain throughout pregnancy • Advise: GWG guidelines and on risks of discordant GWG • Agree: Realistic behavioral goals and create a plan for action • Assist: Identifying and resolving barriers to healthy GWG.
5A’s for patients
Contreras-Martos 29 -2021	Analyze the effectiveness of a multiple health behavior change intervention based on 5A’s to increase physical activity	5A’s integrated in the counseling	• Assess: Brief physical activity assessment and target behaviors • Advise: Provided information • Agree: Specific goal • Assist: Establishing and following an action plan • Arrange: Arranged follow-up support
Costanzo 30 -2006	Compare the effectiveness of five behavioral counseling (BC) sessions with one BC session to increase moderate-intensity physical activity, muscle-strengthening, and stretching activity	The BC intervention was structured in terminology, frequency, intensity, and duration using the 5A’s (assess/ask, advise, agree, assist, and arrange)	• Assess: Activity level, readiness, and barriers • Advise: Moderate-intensity physical activity, gradually increasing length and intensity • Agree: Physical and muscle-strengthening activities • Assist: Self-efficacy enhancement, role modeling • Arrange: Involved setting the follow-up visit
Lewis 37 -2017	Determine the feasibility and acceptability of a pragmatic, primary care-based intervention that incorporated 5A’s counseling and self-control through an activity monitor	All study participants underwent 5 A’s counseling from a counselor	• Assess: Behavioral health risk, physical activity • Advise: To increase physical activity • Agree; each agreement about physical activity goals • Assist: Behavior change strategies • Arrange; follow-up appointment to assess progress and additional issues
Reed 41 -2019	Examine the effectiveness of using the 5A’s model for PA counseling on rural adults’ PA behaviors	PA behavioral counseling embedded in the 5A’s model	• Assess: Current physical activity levels, physical abilities, beliefs, and knowledge • Advise: Health risks, benefits of change, and appropriate amount and intensity of physical activity • Agree: a Personalized action plan; set specific physical activity goals in behavioral terms • Assist: Self-monitoring tools (Fitbit); identified barriers and strategies and social support systems • Arrange: Plan for follow-up visits, made telephone calls, and provided support through text messaging
Viglione 43 -2019	Assess the feasibility and acceptability of goals for eating and moving and its impacts on weight, diet, and physical activity	Goals for Eating and Moving Intervention (GEM) to deliver 5A’s counseling within the context of the patient-centered medical home model	• Assess: Risk and stage of change • Advise: Weight loss and behavior change • Agree: On goals • Assist: Addressing barriers (motivational interviewing) • Arrange: Follow-up or refer patient for further treatment
Wilson 46 -2010	Test a clinician-delivered intervention utilizing community resources for in-depth counseling for unhealthy behaviors including overweight	EMR-based prompt and referral system for the clinician to counsel the patient using the 5 A’s	• Asses: EMR to identify patients prompt to counsel patients: EMT-prompt counseling • Advise: No mention • Agree: Interested in intensive counseling • Assist: Automate patient referrals to an intensive counseling • Arrange: Survey

Intervention information, based on TIDieR, for medical students and residents can be found in Tables 3 and 4. The 5 A’s Framework was used as guiding principles in obesity counseling and included in a formal curriculum, ranging from 3 to 11 hours across 2 days, 3 weeks, 6 weeks, 6 months, or 3 years (Table 3). Two studies also adopted Motivation Interviewing, ³³ Social Cognitive Theory, and Social Ecological Theory. ⁴⁰ Five A’s curricular content was delivered through individual and group methods. Intervention activities included case discussion, role-play, videotape review of own counseling, practicing on standardized patients and debriefing, and clerkship experience with preceptors. First-year medical students in Flocke et al. study received the 5A’s training and then observed and collected data of family medicine physicians’ counseling behavior. ³¹ In Luig et al. study, medical residents wore an empathy suit mimicking a body size of obesity for 15 min followed by a narrative reflection on the experience. ³⁸ Three of the 6 studies had a comparison group that received either the same training after the study ended^34,35 or traditional obesity counseling education. ⁴⁰

Table 3.

Intervention Details in 22 Studies (Why, What, How, and When).

Author-Year	Why	What	How	When and How Much	Control
	Theory/Model	Activities/Materials	Modes of Delivery	Frequency/Length
5A’s for medical students and medical residents
Flocke 31 -2005	No	Training of 8 first-year medical students: • Discussion of scenarios of health behavior • Pilot testing the protocol • Observe and collect data of family medicine physicians counseling behavior	Individual	Half day training during a 6-weeks period	No control
Iyer 33 -2018	Motivational interviewing theory	The curriculum included: • Obesity and 5A’s • Case-based discussion • Motivational interviewing • Practice with simulated patient scenario and with feedback	Group	• Curriculum delivered 4 times across 6 months • Each session 3 hours (2 hrs of didactics and 1 h of motivational interviewing theory and practice)	No control
Jay 34 -2010	No	The 5-hour curriculum included: • Case studies, role-playing, standardized patients for counseling practice • Faculty-facilitated videotape review of residents counseling their own patients	Group, video of own counseling	5 hours in three weekly sections over three weeks	The control received the curriculum until the end of the study
Jay 35 -2013	No	A 5A’s obesity counseling curriculum: • Multiple interactive teaching modalities (didactics, role-playing) • Standardized patients • Videotape review of a patient encounter	Group, video of own counseling	Total 5 hours across three weeks	Residents in the control group received the curriculum 6-8 months later
Luig 39 -2020	No	5A’sTMD course: • Discussed-based lectures • Empathy suit experience for 15 min and complete a one-page narrative reflection on the experience • Standardized patient interviews using the 5A’s • Debrief in small group	Group, individual	8-11 hours in 2 days to complete the course	No control
Ockene 40 -2021	Social cognitive theory and social ecological theory	Multi modal weight management education: • A web-based course • A role-play classroom exercise • A web-patient encounter with feedback • An enhanced clerkship experience with preceptors	Group, individual; web-based	• Across 3 years of curriculum • Web course-4 hours • Preceptors received 30-60 min of training	Traditional weight management education
5A’s for physicians
Carroll 27 -2014	No	Clinicians training: • Effective communication • Didactic materials, PA guidelines, motivation • 5A’s competency checklists • Role-play with standardized patient • In the assist and arrange steps, refer patients to a community exercise program	Individual	4 one-hour training	Received the training 8 months later
Caroll 28 -2016	No	Training included: • Recommendations for PA • Definition of the 5A’s • Eliciting motivation • Problem-solving • Referral to community resources • Standardized patient practice	Individual, group	• Three 1-hr training • One 1-hr standardized patient practice	Received the training 8 months later
Galaviz 32 -2017	RE-AIM framework	Training aimed to increase physicians’ attitudes, perception of control, beliefs, and intentions about PA counseling and with three modules: • Reinforced the international PA guidelines • Understanding of the FITT (frequency, intensity, type, and time of PA) • How to use the 5-A’s model including physicians received prompts from patients vs no prompts	Not clear	• 3-h training to provide 3-5 min of PA counseling	• 18 physicians did not receive prompts • 18 physicians matched by sex/region who did not attend a regional training course
Krist 36 -2008	No	Prompts in electronic linkage system (eLinkS) to promote 5A’s health behavior counseling and automate patient referrals to intensive counseling (group counseling, telephone counseling, or computer care)	Group counseling (weight watchers) telephone counseling, computer care (information website and asynchronous eCounseling) • Patients received 9-month intensive counseling (up to 70 sessions and up to 120 min each session • Weekly report of patient referrals to clinicians	• Clinicians: 1-hour training about eLinkS	None
Welzel 45 -2021	No	The 5A’s weight management online tutorial included an introduction, five knowledge sections and a short knowledge quiz (7 questions) at the end	Individual online tutorial	Each training was 40 min; completed in 2 months	Received access to the 5A’s online tutorial after the trial
5A’s for non-physician health care providers
Amini 25 -2023	WHO-healthy lifestyle module	• 5A’s healthy lifestyle counseling skills training workshop • WhatsApp to download virtual education materials	Group discussion, video, clip	• 60 min workshop: 50 min of video and 10 min of motion graph	Usual care
Campbell-Scherer 26 -2019	Theoretical domains framework	• Team-based interactive education training for front-line workers (available online) • Alberta health services chronic disease management training (AHSCDMT) • Edmonton Southside Primary Care Network’s obesity training (ESPCNOT)	Group discussion, video, and internet link	• 24 hours: 12 education sessions (2 hrs each) across 6 months • 7 hours: AHSCDMT • 4 hours: ESPCNOT	AHSCDMT (7 hrs) ESPCNOT (4hrs)
Malan 39 -2016	Motivational interviewing	Brief behavioral change counseling workshop: • The 5 A’s • A guiding style from motivational interviewing • Counseling standardized patients immediately before and after the training and again 6 weeks later	Group and individual	Workshop: 8 hours (four 2-hour sessions)	No control
Rueda-Clausen 42 -2014	No	• Standardized training about the 5A’s of obesity management • Printed and electronic material to facilitate and implement the 5A’s tool clinical practice	Individual, training became a certified online module (https://www.iaso.org/)	Training 90 mins	No control
Weeks 44 -2020	Health belief model	• Workshop on gestational weight gain • Slides (use of 5A’s tool) • Physical copies of the 5A’s (checklists, patient handouts, a desktop tool, and an health care provider [HCP] information booklet)	Group	60 min standardized training workshop for participating HCPs	No control
5A’s for patients
Contreras-Martos 29 -2021	Transtheoretical model of behavior change	• Personal screening (assessing stage of change) • 5A’s based individual counseling including prescribing very brief intervention (information) or brief intervention (group sessions and community resources) • A coded acting patient session to reinforce skills • Community health assets and referral to PA places • Information and communication technology for patients	Individual, group, APP, pedometers, text messages	• Provider training 20 hours • Group sessions lasted 90-120 min for patients	Brief advice on the prevention of cardiovascular and mental diseases
Costanzo 30 -2006	Health promotion model, social cognitive theory	• 5 behavioral counseling sessions (BC) based on 5A’s • Baseline instructions on physical activity barriers, goals • Stretching activity, moderate-intensity physical activity and strengthening activity twice a week • 2 resistive bands and a videotape about how to use resistive bands • Record activity in logs	Individual, resistive bands, videotape	• Intervention-12 weeks • Total 150-min counseling (30-min each session x 5 sessions) • 3.5 hours of data collection	• Baseline instruction • 1 BC at week 1 • Activity logs • Resistive bands and video after the study
Lewis 37 -2017	RE-AIM (Reach, effectiveness, adoption, implementation, maintenance) framework	TAME Health Pilot: • Patients received 5-10 min 5A’s counseling by a counselor trained in exercise physiology and motivational interviewing • Patients received an UP24 wearable device to monitor physical activity and sleep, and the APP tracked diet and weight • Stakeholders had an opportunity to test UP24 for 4 weeks	Individual, electronic activity monitor, APP	Participants monitored activity for 12 weeks	• 5-10 min of 5A’s counseling • Pedometer and an activity log
Reed 41 -2019	None	• 5A’s based behavioral counseling • Subjects wore Fitbit charge 2 on the nondominant wrist at all times during the day • Completed a physical activity action plan through a Google Form monthly 3 times • Text messages for encouragement, motivation, goal setting, mitigating barriers • Three standardized letters for encouragement and support	Individualized feedback	12 weeks long intervention	• Fitbit charge 2 • Usual care
Viglione 43 -2019	MOVE! a national, intensive weight management program	Weight counseling using 5A’s and three components: Patient-centered medical home model • Health coaches • tablet-delivered GEM tool • Patient aligned care teams	• Individual telephone counseling	• Health coaches: 25 hrs of motivational interviewing and protocol training • PCPs: One time training (15-20 min) on communication. Goals and barriers • Veterans: 1 hr session for tablet-GEM and self-management tools and up to 12 coaching calls (∼25 min each)	• Pamphlets (screening tests, immunizations, stress management, tobacco/alcohol use, and physical activity) • Handouts to write down and discuss goals with PCPs
Wilson 46 -2010	No	Patients referred to intensive counseling: • Group counseling (commercial weight watchers weight loss program • Individual telephone) counseling • Computer-based counseling/e-counseling	Group and individual	Up to 9 months but surveyed at 4 months	Counseling by the clinician or a decision not to address overweight

Table 4.

Intervention Details in 22 Studies (Where, Who, Tailoring, Modification, and How Well).

Author-Year	Where	Who	Tailoring	Modifications	How well
	Location of the Intervention	Intervention Provider	Personalized, Titrated, Adapted	Changes	Attrition, Adherence
5A’s for medical students and medical residents
Flocke 31 -2005	8 family medicine clinics	Family medicine practice	No	No	3.5% patients declined interview
Iyer 33 -2018	Primary care	Resident program	No	No	32% (9/28) did not completed pre and post surveys
Jay 34 -2010	Primary care	Resident program faculty	No	No	3.7% attrition (3/81) in the intervention group
Jay 35 -2013	Primary care setting	Resident program faculty	No	No	24.7% patients did not have a 12-month visit
Luig 39 -2020	Family practice	Family medicine training program	No	Lecture and scheduling refined in the 2nd cohort	69% residents completed questionnaires
Ockene 40 -2021	8 medical schools (4 private and 4 public)	Medical schools	No	No	Attrition: 23.7% in the intervention group and 36.5% in the control group at 3 years
5A’s for physicians
Carroll 27 -2014	2 federally qualified health centers	No mention	No	No	• 23.1% (3/13) physicians relocated/retired; 16.7% (1/6) attrition in intervention and 28.7% (2/7) in control at 6 months • 1.8% (6/325) patients did not complete surveys at 6 months
Caroll 28 -2016	1 federally qualified health center-primary care	No mention	No	No	No mention
Galaviz 32 -2017	13 sanitary regions -primary care	Secretary of health employees with a MD and PhD degree and an expert in PA counseling	No	No	• 5A’s adoption by physicians (1-52%) in practice • The duration of each training session varied, ranging from 30 to 247 min (mean 170 ± 54 min) • 42.2% (136/322) of physicians and 30.9% of patients (212/687) did not complete questionnaires at 6 months
Krist 36 -2008	9 primary care practices	Trained counselors	Patients self-selected a counseling program	Stopped 5 wks after start due to limited funds	61% survey response from counselors
Welzel 45 -2021	50 general practices	Online tutorial developed by the Canadian Obesity Network	Participants received CMU points	No	50 GPs: • 84% response rate at 6 months and 33% at 12 months follow-up • 76% completed the 5A’s tutorial entirely (average time: 35 min) 135 patients: • 94.1% and 88.1% response rates at 6 months and 12 months follow-up, respectively
5A’s for non-physician health care providers
Amini 25 -2023	Health centers	No mention	Workshop available as a virtual in-service training course	No	Health providers: • 1.6% (3/190) attrition rate at 1 week (1.1% or 1/95 in the intervention group and 2.1% or 2/95 in the control group) Clients: • 5.3% attrition rate at 2 months (3.2% or 3/95 in the intervention group and 2.1% or 2/95 in the control group)
Campbell-Scherer 26 -2019	Primary care network	A dietitian and external content experts	The intervention sessions, video, and tools available online	No	• 20% attrition (intervention) and 0% (control) at 9 months • Clinical variability among nurses
Malan 39 -2016	Primary care system	Primary care system	No	No	No mention
Rueda-Clausen 42 -2014	4 primary care settings	Module adopted from the Canadian Obesity Network	No	No	Pre and post surveys on different patients
Weeks 44 -2020	2 prenatal health centers	Materials developed by the Canadian Obesity Network and the 5A’s leadership team	None	No	No mention
5A’s for patients
Contreras-Martos 29 -2021	25 primary health centers	• Professionals at the primary care centers • Exercise instructors in community sports centers or outdoor activities	Intervention depending on target behavior and stage of change	No	• Attrition rates: 25% (intervention group) vs 19% (control group) at 12 months • About half of the intervention group received at least one type of intervention
Costanzo 30 -2006	An urban community	Advanced practice nurse	No	No	9.8% (5/51) from both groups withdrew at 12 weeks
Lewis 37 -2017	2 primary care clinics	Counselor trained in exercise physiology and motivational interviewing	No	Focus groups became one-on-one interview	Total 35% attrition rate (5% or 1/20 in the intervention group and 30% or 6/20 in the control group
Reed 41 -2019	A primary care setting	Nurse practitioners	Individualized tailored text messages	No	Total attrition rate 6.7% (10.3% or 3/29 in the intervention group and 3.3% or 1/30 in the control group)
Viglione 43 -2019	VA-primary care	Student coaches	GEN tool generated tailored education materials	Scheduled baseline visits independent of PCP visits to increase the pool of eligible patients	Total attrition 15.6% (18.2% or 4/22 in intervention group and 13% or 3/23 in the control group) at 12 months
Wilson 46 -2010	9 primary care practices	Trained counselors	Patients self-selected a counseling program	Group counseling discontinued at the 5th week	• 62% returned surveys at baseline • 60% returned surveys at 4 months • 37% response to both surveys

Five of the 6 medical student/resident studies were conducted in the primary care setting, and one was implemented in 8 medical schools (Table 4). No major modifications were reported except one study that refined lecture and scheduling for the 2^nd cohort of family medicine residents. ³⁸ Adherence data were not commonly reported. Attrition rates varied from 3.7% to 36.5% between pre and post intervention surveys.

5A’s Interventions Focused on Physicians

Five articles reported 5A’s interventions conducted with family medicine and primary care physicians.^{27,28,32,36,45} These 5 studies aimed to improve physician-patient communication and physicians’ counseling skills related to physical activity (n = 3), body weight (n = 1), and other unhealthy behavior (n = 1) (Table 2). The 5 A’s Framework was integrated into observation checklists, weight counseling training programs, weight counseling document guide, or electronic medical records. Advise, Assist, and Agree were included in all 5 studies, Ask and Agree in 4 studies, and Assess in 2 studies. Krist et al. added “Address” when testing an electronic linkage system to help clinicians perform behavioral counseling. ³⁶

Table 3 (intervention details based on TIDieR) shows that the Research, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework was included in one study. ³² Physician counseling training programs varied from 40 minutes to 4 hours in length and were delivered via individual, group, and online formats. The training also included problem-solving, standardized patient practice, practice guidelines, and knowledge quizzes. One study used prompts built in electronic medical records to help clinicians perform the 5A’s counseling and refer patients to different counseling modalities (group, telephone or computer care, and physician). ³⁶ Three studies used a wait-list design, where the control group received the training 6-8 months after the intervention.^27,28,45

All 5 studies were conducted in primary care settings (Table 4, TIDieR information). Most articles did not clearly address who delivered the training to physicians. In one study, an officer from the Secretary of Health (Mexico) provided the training. ³² Trainees in one study received continued medical education points. ⁴⁵ Recruitment in another study was discontinued after 5 weeks due to limited funds. ³⁶ Carroll et al. reported attrition rates of 16.7% and 28.7% at 6 months for the intervention group and the control group, respectively. ²⁷ Galaviz et al. provided adherence data which included the duration of each training session from 30 to 247 minutes. ³²

5A’s Interventions Focused on Non-physician Health Care Providers

Five studies involved non-physician health care providers (midwives, nurses, public health workers, mental health workers, and dietitians).^{25,26,39,42,44} The 5A’s Framework was adopted to develop (1) an education program or a checklist to facilitate provider–patient communication or (2) a questionnaire to collect data about provider counseling behavior (Table 2). Ask, Assess, and Assist were included in 4 studies, Advise in 3 studies, and Agree and Arrange in 2 studies. One study added an “Alert” to their intervention, which was to provide tailored information to the patient and elicit understanding. ³⁹ Clinicians in this study provided behavioral counseling to standardized patients immediately before and after training and again 6 weeks later for skill assessment.

Tables 3 and 4 capture TIDieR related information. Researchers adopted the WHO-Healthy Lifestyle module, Theoretical Domains Framework, Motivational Interviewing, and Health Belief Model in 5A’s interventions conducted with non-physician health care workers (Table 3). Five A’s Framework integrated training workshops ranged from 60 minutes to 24 hours over 12 education sessions. Workshops included group discussions, video watching on the Internet or via application, and printed handouts and checklists. Two of the 5 studies included a control group.

All 5 studies were implemented in the primary care setting, including 2 prenatal health centers ⁴⁴ (Table 4). Dietitians and nurse practitioners delivered the intervention training to non-physician clinicians. Tailoring activities included making the training online and providing individualized text messages. Attrition and adherence data were not reported in 3 of the 5 studies. Attrition was low (1.6% vs 2.1% for intervention and control) at 1 week in one study ²⁵ and high (20% vs 0% in intervention and control) at 9 months in another study. ²⁶

5A’s Intervention Focused on Patients

The 5A’s Framework was used in 6 studies to improve patient outcomes. These studies intended to improve patient’s physical activity (n = 4),^30,37,41,43 weight (n = 1), ⁴⁶ and weight, diet, and physical activity (n = 1) ⁴³ (Table 2). The 5 A’s Framework was included in behavioral counseling or electronic medical records in the patient-focused studies. All 6 patient-focused studies adopted Assess, Advise, Agree, Assist, and Arrange, and none included Ask.

Several additional theories/models were included in these studies, including Transtheoretical Model of Behavior Change, Health Promotion Model, Social Cognitive Theory, and RE-AIM Framework (Table 3). The 5A’s Framework was used by study interveners to provide counseling for patients, deliver group sessions, coach patients, and refer patients to community resources. Often, patients received additional instructions, such as how to use wearable devices to track, monitor, and record diet, physical activity, and sleep. Patients also received coaching calls and participated in group sessions. Training for counselors and study interveners lasted 15-20 minutes to 20-25 hours. Each coaching call was 25 minutes, and each group session was 90-120 minutes long. The length of patient-focused interventions was 12 weeks to 9 months. One intervention used an electronic system to encourage patients to choose one of the three intensive counseling methods: Weight Watchers Program, individual telephone counseling, or computer-based counseling. ⁴⁶ All 6 patient-focused studies included a comparison group.

Table 4 shows that 5 of the 6 patient-focused studies recruited study participants from primary care settings. Exercise instructors, advanced practice nurses, trained counselors, and health coaches delivered the interventions. One study conducted via the U.S. Veterans’ Administration health system involved undergraduate, graduate, and pre-medical students as health coaches. ⁴³ Tailoring and modifications of the 5A’s Framework intervention were reported in several studies. Interventions were tailored to provide information and counseling based on a person’s stage of change and allowing the patient to self-select a counseling program. Some study modifications included: changing focus groups to one-on-one meetings, scheduling baseline visits independent of primary care provider visits, and discontinuing free Weight Watcher’s program referrals at week 5 of the study. One study had a high attrition rate of 35%, ³⁷ while others reported a rate of less than 20%.^41,43

Discussion

This systematic review, including 22 quantitative articles, aimed to assess how the 5A’s Framework was integrated, including implementation details, in research on obesity and weight counseling. We found that the 5A’s Framework was adopted in studies conducted primarily in the primary care setting across the U.S. and other countries. The finding agrees with the recommendations addressed in previous publications about primary care being an ideal practice setting to implement 5A’s based obesity and weight counseling.^{7,13-15,17,18}

Most of the studies in our analysis integrated the 5A’s Framework in obesity and weight counseling trainings as formal medical curricula and continuing education programs for physicians in training, current physicians, and non-physician health care workers to influence (1) their obesity and weight counseling behaviors and communication with clients and (2) patients’ obesity and weight loss behaviors. Some researchers also used the 5A’s Framework as a validation tool to assess obesity/weight counseling behaviors/skills of health care providers, and the validation tools could be translated into a skills observation checklist and/or self-assessment questionnaire.

A minority of the studies in our review was patient-focused to improve the patients’ obesity-related behaviors and weight outcomes. Those patient-focused studies not only integrated the 5A’s Framework in training the people who provided a proposed intervention but also combined additional behavior change strategies in the intervention, such as self-monitoring of diet and physical activities or offering outside primary care support programs. These studies all included a comparison group but did not include the component of Ask.

Various combinations of the 6 components (Ask, Assess, Advise, Advise, Agree, and Arrange) were selected by researchers to conduct their studies. Across the 4 categories of 5 A’s interventions in our analysis, Advise and Assist were most frequently included than the other components. Additionally, the 6 patient-focused studies in our review all adopted Assess, Advise, Agree, Assist, and Arrange, and none included Ask. In a previous systematic review, Assist and Arrange were reported most desired by patients, but Advise and Assess were most frequently practiced by physicians. ¹⁴ Whitlock et al. viewed the 5A’s as a unifying construct: each A is unique and together the 5A’s components become an organizational construct for clinical weight counseling. ¹³ More research is needed to assess whether or not each component leads to different patient outcomes and which combination of the components results in more weight loss or better weight maintenance. The Multiphase Optimization Strategy (MOST) could be a useful framework in trial design to determine the relationship between 5A’s components and study outcomes relevant to patient weight or provider counseling behaviors. ⁴⁷ Before such research data are available, it may be important to regard the 5A’s as a unifying construct for obesity and weight counseling, rather than emphasize individual components in the 5 A’s Framework.

A unique contribution of our systematic review is the assessment of the 5A’s Framework intervention details using the TIDieR checklist. TIDieR is thought to improve replicability of intervention and comparability between studies. ²³ Ideally, similar results, such as effect sizes and confidence intervals, generated from multiple studies or replications are likely to support a theory or hypothesis or to estimate the evidence.^19,48 Some researchers recommend conceptual replication as an attempt to test the same fundamental idea using different dependent variables, designs, and participant population. ⁴⁹ We are not able to provide, based on our systematic review, standard intervention procedures for 5A’s based interventions. However, our analysis findings offered similarities and differences in intervention details across studies with various designs and study participants that tested the fundamental idea of the 5A’s Framework. Some similarities included integration of the 5A’s Framework in counseling trainings, intervention conducted in the primary care setting, and involvement of a comparison group in 5A’s based studies that were focused on patients. Many differences and variations were also noticed across studies in the mode of intervention delivery, duration of intervention, modification and tailoring during intervention, and whether to use triangulation of additional theories and frameworks, such as health promotion, behavior change, and motivation interviewing theories, in a 5A’s based intervention. Certainly, more research is needed, especially well-designed studies that pay attention to intervention details. As health care is becoming more complex due to advanced technologies and obesity treatment modalities, more studies for multilevel interventions, such as integrating the 5A’s Framework in electronic medical records to enhance obesity/weight counseling, referral, and follow-up among interdisciplinary care teams or combining the 5A’s Framework behavioral counseling with pharmacological and surgical treatment modalities for obesity, are also recommended.

Practice Implications

Our review findings imply that health care providers working in the primary care setting have the privilege to begin and continue the conversation about weight with their clients and the providers will need to have the knowledge and skills to use the 5A’s Framework in weight counseling. Five A’s or other weight and obesity counseling continuing education could be provided for newly hired providers and re-enforced with annual continuing education workshops. Care system modification in the primary care setting, including software and additional personnel, will need to be modified to facilitate providers’ assessment, documentation, follow-up, and billing and reimbursement. Nevertheless, potential challenges could occur when implementing a 5A’s based weight and obesity counseling program, and challenges may include obtaining the buy-in from the administration (e.g., developing education programs), the provider team (e.g., time constraints), and supporting staff (e.g., change patient flow), and mobilizing resources to offset costs from the implementation.

As the 5A’s Framework is largely applied to the development of obesity and weight counseling skills and the validation of competencies of current and future care providers, another practice implication is to include the 5A’s Framework in education programs and licensure, board, and clinical certification exams to reinforce the importance of obesity and weight counseling and help improve the obesity epidemic.

Limitations

Limitations in this systematic review are related to the quality of the available evidence, including a lack of information concerning intervention adherence and dose, limited study attrition data, and a limited number of fully powered randomized controlled trials (RCTS). Future research should provide intervention adherence and dose intended, delivered, and received. ⁵⁰ Our systematic review was focused on intervention details. We did not perform meta-analysis because studies included in our analysis were not all RCTs. Our analysis could not address whether the 5A’s based research is efficacious in changing care provider’s counseling behaviors or the patient’s weight outcomes.

Conclusion

This systematic review examined how the 5A’s Framework was integrated in research on obesity and weight counseling. Findings indicated that the 5A’s Framework has been integrated in interventions with the intent to impact counseling competencies/skills of the health care provider and the patient’s weight management behaviors and outcomes. The 5A’s Framework can be used in training programs for medical students and physician and non-physician health care providers. It can also be utilized to develop assessment tools to evaluate counseling behaviors of health care providers.

ORCID iDs

Carol Shieh https://orcid.org/0000-0003-2594-1387

Anna Liss Jacobsen https://orcid.org/0000-0002-7212-3830