Attach 10

OMB #: 0925-NEW
Expiration Date: xx/xxxx
This survey should take approximately 20 minutes to complete

Could your genes predict your weight?
Which of the following best describes you?

Q1.

□

I am trying to lose weight

□

I am trying to keep off the weight that I have lost

□

I am actively trying not to gain any weight

□

I am trying to gain weight

□

I don’t think about my weight

Where you get information
Where do you get information about factors that influence weight (e.g., diet, exercise)? These can be places where you
look for information, or places where you see this information even if you aren’t looking for it.
Choose all that apply:
People

Q2a.

□
□
□
□
□

Family
Friends/co-workers
Your primary health care provider (e.g., your personal doctor)
Another health care provider
Clergy

Media and Online

□
□
□
□
□
□
□
□
□
□
□

Nutrition, exercise or weight loss websites
Scientific websites or journals
Social networks, online message boards or forums
Blogs
Mobile apps
Magazines (online or paper)
Newspapers (online or paper)
Television
Radio
Books
Brochures, pamphlets

Other

□
□
□
□
□

School or classes
Workplace education
Weight loss program or group
I do not look for or see this information
Other (Please List):

Here are the places where you get information about factors that influence weight:
b. Which source gives the best information
Q2b-d.

c. Which source gives the second-best information
d. Which source gives the third-best information

Discussing your weight
With whom do you discuss your weight (choose all that apply)?

Q3.

□

Spouse/partner

□

Family

□

Close friends

□

Casual friends/co-workers

□

Clergy

□
□

Your primary health care provider (e.g., your personal doctor)
Another health professional

□

Weight loss group leader or members

□

People on online forums/blogs

□

I do not discuss my weight with anybody

Talking with your primary care provider:
During this survey, please think of “your primary care provider” as the health care professional you see to take care of your
overall health. This would be the person you would go to for medical checkups when you are well. This could be a doctor,
another health care provider like a nurse practitioner or physician assistant, or a group of medical professionals like the
doctors at a clinic.

How much do you look to your primary care provider for help with your weight?
Q4.

1----------------- 2----------------- 3----------------- 4----------------- 5----------------- 6-----------------7
Not at all

Somewhat

Very much

How much do you think it’s your primary care provider’s responsibility to help you with your weight?
Q5.

1----------------- 2----------------- 3----------------- 4----------------- 5----------------- 6-----------------7
Not at all

Somewhat

Very much

Would discussing weight with your primary care provider be helpful to you?
Q6.

1----------------- 2----------------- 3----------------- 4----------------- 5----------------- 6-----------------7
Not at all

Somewhat

Very much

Your thoughts about the causes of weight
How much do you think someone’s body weight is inherited or influenced by genetics?
Q7.

1----------------- 2----------------- 3----------------- 4----------------- 5----------------- 6-----------------7
Not at all

Somewhat

Very much

How much do you think someone’s body weight is caused by overeating and not exercising?
Q8.

1----------------- 2----------------- 3----------------- 4----------------- 5----------------- 6-----------------7
Not at all

Somewhat

Very much

There are genetic factors that influence people’s weight. Right now, it is possible to find out if someone has a slightly higher
risk of being overweight (e.g., gaining an extra 3-7 pounds) by testing whether or not they have certain versions of a gene.
Thinking about this information…
How interested are you in learning more about how genetics affects weight?
Q9.

1----------------- 2----------------- 3----------------- 4----------------- 5----------------- 6-----------------7
Not at all

Somewhat

Very much

How interested are you in learning more about how your genes affect your weight?
Q10.

1----------------- 2----------------- 3----------------- 4----------------- 5----------------- 6-----------------7
Not at all

Somewhat

Very much

Again, thinking about this information…
How much would you look to your primary care provider for help with your weight?
Q11.

1----------------- 2----------------- 3----------------- 4----------------- 5----------------- 6-----------------7
Not at all

Somewhat

Very much

How much do you think it’s your primary care provider’s responsibility to help you with your weight?
Q12.

1----------------- 2----------------- 3----------------- 4----------------- 5----------------- 6-----------------7
Not at all

Somewhat

Very much

Would discussing weight with your primary care provider be helpful to you?
Q13.

1----------------- 2----------------- 3----------------- 4----------------- 5----------------- 6-----------------7
Not at all

Somewhat

Very much

In the future, it could be possible to look at someone’s entire genome to predict much more of their risk for being overweight.
It might also be possible to create a personalized diet and exercise program based on someone’s genes. This could make it
easier for people to lose weight or to maintain a healthy weight.
If this were possible…
How interested would you be in learning more about how genetics affects weight?
Q14.

1----------------- 2----------------- 3----------------- 4----------------- 5----------------- 6-----------------7
Not at all

Somewhat

Very much

Where would you go to get more information about how genetics affects weight? (choose all that apply)
People

Q15a.

□
□
□
□
□
□

Family
Friends/co-workers
Your primary health care provider
Another health care provider
Genetic counselor
Clergy

Media and Online

□
□
□
□
□
□
□
□
□
□
□

Nutrition, exercise or weight loss websites
Scientific websites or journals
Social networks, online message boards or forums
Blogs
Mobile app
Magazines (online or paper)
Newspapers (online or paper)
Television
Radio
Books
Brochures, pamphlets

Other

□
□
□
□
□
□

School or classes
Workplace education
Weight loss program or group
Genetic testing company
None
Other (Please List):

Here are the places where you would go to get more information about genetics and weight:
Q15b-d.

b. Which source gives the best information
c. Which source gives the second-best information
d. Which source gives the third-best information

If this were possible…
If you could choose, where would you want to have your genes tested?

Q16.

□
□
□
□
□
□
□
□
□

I would not want to have my genes tested
A private genetic testing company
Your medical insurer
Your primary health care provider
A genetic counselor
Another health care provider or clinic
A government program
I don’t know
Other (Please List):

How would you prefer to get the results of your genetic test?

Q17.

□
□
□
□
□
□
□

I would not want the results of my genetic test
Over the internet
In a mailed report
From your primary health care provider
From a nutritionist
From a genetic counselor
From another health care professional or clinic

□
□
□

In a weight loss group or program
I don’t know
Other (Please List):

How would you prefer to get recommendations for diet and exercise based on your genetic test results?

Q18.

□
□
□
□
□
□
□
□
□
□

I would not want recommendations for diet and exercise based on my genetic test results
Over the internet
In a mailed report
From your primary health care provider
From a nutritionist
From a genetic counselor
From another health care professional or clinic
In a weight loss group or program
I don’t know
Other (Please List):

With whom would you want to discuss your genetic test results? (choose all that apply)

Q19.

□
□
□
□

Spouse/partner
Family
Close friends
Casual friends/co-workers

□
□
□
□
□
□
□
□

Clergy
Your primary health care provider
A nutritionist
A genetic counselor
Another health professional
Weight loss group leader or members
People on online forums/blogs
I would not want to discuss my results with anybody

Again, If this were possible…
How much would you look to your primary care provider for help with your weight?
Q20.

1----------------- 2----------------- 3----------------- 4----------------- 5----------------- 6-----------------7
Not at all

Somewhat

Very much

How much do you think it would be your primary care provider’s responsibility to help you with your weight?
Q21.

1----------------- 2----------------- 3----------------- 4----------------- 5----------------- 6-----------------7

Not at all

Somewhat

Very much

Would discussing weight with your primary care provider be helpful to you?
Q22.

1----------------- 2----------------- 3----------------- 4----------------- 5----------------- 6-----------------7
Not at all

Somewhat

Very much

How much would you look to your primary care provider to talk with you about how your genes affect your weight?
Q23.

1----------------- 2----------------- 3----------------- 4----------------- 5----------------- 6-----------------7
Not at all

Somewhat

Very much

What do you think your results would be if you had your genes tested to find out your risk of becoming overweight?

Q24.

□
□
□
□
□
□

Much higher risk of being overweight
Somewhat higher risk of being overweight
Average risk of being overweight
Somewhat lower risk of being overweight
Much lower risk of being overweight
I don’t know

About your weight
How important is it to you to have a healthy weight?
Q25.

1----------------- 2----------------- 3----------------- 4----------------- 5----------------- 6-----------------7

Not at all

Somewhat

Q26.

How tall are you?

Q27.

How much do you weigh?

feet;

inches
pounds

Very much

Right now, do you think you are :
Q28.

□
□
□
□

underweight
about right
overweight
very overweight

Throughout your life, how much of the time have you been on a diet, trying to follow a diet, or in some way limiting how
much you were eating in order to lose weight or keep from regaining weight you had lost?
Q29.
1--------------------2--------------------3--------------------4--------------------5--------------------6--------------------7
None or hardly any of the time

Nearly all of the time

About your primary health care provider
Do you have a primary health care provider?
Q30.

□
□

yes
no

Do you see your primary health care provider for checkups when you are well?
Q31.

□
□

yes
no

Who is your primary health care provider?
Q32.

□
□

A doctor
A physician assistant

□
□
□

A nurse practitioner
A team/group of health care providers
Other (Please List):