Behavioral Treatment of Obesity in Patients Encountered in Primary Care Settings

Abstract

IMPORTANCE In 2011, the Centers for Medicare and Medicaid Services (CMS) approved intensive behavioral weight loss counseling (i.e., approximately 14, 10–15 minute, face-to-face sessions in 6 months) for obese beneficiaries in primary care settings, when delivered by physicians and other CMS-defined primary care practitioners (PCPs). OBJECTIVE To conduct a systematic review of behavioral counseling for overweight/obese patients recruited from primary care, as delivered by PCPs working alone or with trained interventionists (e.g., medical assistants, registered dietitians), or by trained interventionists working independently. EVIDENCE REVIEW We searched PubMed, CINAHL, and EMBASE for randomized controlled trials (January 1980–June 2014) which: recruited overweight/obese patients from primary care; provided behavioral counseling (i.e., diet, exercise, and behavior therapy) for ≥3 months, with ≥6 months post-randomization follow-up; included ≥15 participants/treatment group and objectively measured weights; and had a comparator, an intention-to-treat analysis, and attrition <30% at 1 year or <40% at longer follow-up. FINDINGS Review of 3,304 abstracts yielded 12 trials (with 3,893 total participants) that met inclusion/exclusion criteria and pre-specified quality ratings. No studies were found in which PCPs delivered counseling following CMS guidelines (14 sessions in 6 months). Mean 6-month weight changes (relative to baseline) in the intervention group ranged from −0.3 to −6.6 kg, with corresponding values of +0.9 to −2.0 kg in control group. Weight loss in both groups generally declined with longer follow-up (12–24 months). Interventions that prescribed both reduced energy intake (e.g., ≥500 kcal/day deficit) and increased physical activity (e.g., ≥150 minutes/week of walking), with traditional behavior therapy, generally produced larger weight loss than interventions without all three specific components. In the former trials, more treatment sessions, delivered in person or by phone by trained interventionists, were associated with greater mean weight loss and likelihood of losing ≥5% of baseline weight. CONCLUSIONS AND RELEVANCE Intensive behavioral counseling can induce clinically meaningful weight loss, but there is little research on PCPs providing such care. The present findings suggest that a range of trained interventionists, who deliver counseling in person or by telephone, could be considered in treating overweight/obesity in patients encountered in primary care.

Randomised controlled trial and economic analysis of an internet-based weight management programme: POWeR+ (Positive Online Weight Reduction)

“…5,8,11 In contrast, we found that for a behavioural internet intervention, such as POWeR+, very restricted face-to-face and remote follow-up is effective (median of four contacts, comprising 6-monthly weighing, brief telephone calls and e-mails). The weight loss achieved with POWeR+ compares favourably with other internet-based interventions, which on average 10 (albeit with high heterogeneity) have led to only short-term weight loss, of < 1 kg compared with no treatment controls or < 2 kg if combined with face-to-face support (in a review based mainly on studies of motivated volunteer samples).…”

Costs and outcomes of increasing access to bariatric surgery for obesity: cohort study and cost-effectiveness analysis using electronic health records

“…This is in contrast to presently available non-surgical interventions for obesity, which generally have only small and generally short-lived effects. 29,96,97 Based on these results, the wider use of bariatric surgery may be justified in the management of people with severe and morbid obesity. A major concern remains that the social and environmental drivers of the increase in morbid obesity should not remain unchecked.…”

“…95 In practice, access to weight-management interventions may be limited 28 and systematic reviews show that weight-management interventions have only small and poorly maintained effects on body weight. 29,96 In order to understand the frequency with which reductions in BMI may occur in a large population, this part of the study aimed to estimate the probability of an obese individual attaining normal body weight, or a reduction of 5% in body weight in the absence of bariatric surgery. The results of this study have been published open access in the American Journal of Public Health (© American Public Health Association).…”

Managing with Learning Disability and Diabetes: OK-Diabetes – a case-finding study and feasibility randomised controlled trial

“…One is the number of face-to-face sessions involved. Recent reviews been inconsistent on whether or not number of sessions or hours of personal contact is an important determinant of success in changing risks for diabetes onset or cardiovascular disease, [197][198][199][200][201] but the most effective programmes seem to have more than three contact sessions. This is a dilemma that is yet to be resolved in debates, for example about national diabetes prevention strategies, because interventions based on minimal patient contact are largely ineffective; however, more intensive contact is unfeasible at the scale required by the population burden and is associated with poor rates of take-up.…”