Effect of Behavioral Therapy With In-Clinic or Telephone Group Visits vs In-Clinic Individual Visits on Weight Loss Among Patients With Obesity in Rural Clinical Practice

Abstract

IMPORTANCE Rural populations have a higher prevalence of obesity and poor access to weight loss programs. Effective models for treating obesity in rural clinical practice are needed.OBJECTIVE To compare the Medicare Intensive Behavioral Therapy for Obesity fee-for-service model with 2 alternatives: in-clinic group visits based on a patient-centered medical home model and telephone-based group visits based on a disease management model. DESIGN, SETTING, AND PARTICIPANTS Cluster randomized trial conducted in 36 primary care practices in the rural Midwestern US. Inclusion criteria included age 20 to 75 years and body mass index of 30 to 45. Participants were enrolled from February 2016 to October 2017. Final follow-up occurred in December 2019.INTERVENTIONS All participants received a lifestyle intervention focused on diet, physical activity, and behavior change strategies. In the fee-for-service intervention (n = 473), practice-employed clinicians provided 15-minute in-clinic individual visits at a frequency similar to that reimbursed by Medicare (weekly for 1 month, biweekly for 5 months, and monthly thereafter). In the in-clinic group intervention (n = 468), practice-employed clinicians delivered group visits that were weekly for 3 months, biweekly for 3 months, and monthly thereafter. In the telephone group intervention (n = 466), patients received the same intervention as the in-clinic group intervention, but sessions were delivered remotely via conference calls by centralized staff. MAIN OUTCOMES AND MEASURESThe primary outcome was weight change at 24 months. A minimum clinically important difference was defined as 2.75 kg. RESULTS Among 1407 participants (mean age, 54.7 [SD, 11.8] years; baseline body mass index, 36.7 [SD, 4.0]; 1081 [77%] women), 1220 (87%) completed the trial. Mean weight loss at 24 months was -4.4 kg (95% CI, -5.5 to -3.4 kg) in the in-clinic group intervention, -3.9 kg (95% CI, -5.0 to -2.9 kg) in the telephone group intervention, and -2.6 kg (95% CI, -3.6 to -1.5 kg) in the in-clinic individual intervention. Compared with the in-clinic individual intervention, the mean difference in weight change was -1.9 kg (97.5% CI, -3.5 to -0.2 kg; P = .01) for the in-clinic group intervention and -1.4 kg (97.5% CI, -3.0 to 0.3 kg; P = .06) for the telephone group intervention.CONCLUSIONS AND RELEVANCE Among patients with obesity in rural primary care clinics, in-clinic group visits but not telephone-based group visits, compared with in-clinic individual visits, resulted in statistically significantly greater weight loss at 24 months. However, the differences were small in magnitude and of uncertain clinical importance.

Weight loss in primary care: A pooled analysis of two pragmatic cluster‐randomized trials

“…Results from the PROPEL trial were previously reported; the PROPEL-clinic/phone group produced clinically significant weight loss at 24 months compared with PROPEL-UC (17). Furthermore, results of the REPOWER study indicated that the REPOWERclinic-group intervention produced significantly greater weight loss than the REPOWER-clinic-individual group, but results for the REPOWER-phone-group arm were not significantly different than the REPOWER-clinic-individual group (18). The results of the current investigation are consistent with the conclusions of a recent review that high-intensity behavioral counseling in primary care settings, when delivered in-person, by phone, or electronically, produce clinically significant weight loss (4-7 kg), whereas low-and moderateintensity counseling produce only modest weight loss (1-2 kg) (13).…”

“…*Patients who became pregnant, had bariatric surgery, or developed a major illness and/or died were removed from the REPOWER trial a priori; patients who became pregnant, had bariatric surgery, or developed a major illness and/or died were retained in the PROPEL trial, and their data were removed beyond the time the event occurred. PROPEL, Promoting Successful Weight Loss in Primary Care in Louisiana trial; REPOWER, the Rural Engagement in Primary Care for Optimizing Weight Reduction trial outcome in the PROPEL trial was percentage of weight loss from baseline to 24 months, whereas the primary outcome in the REPOWER trial was absolute weight loss (kilograms) from baseline to 24 months (17,18). In the present study, we present results for both outcomes.…”

“…The PROPEL trial was approved by the institutional review board (20), and the trial-specific CONSORT diagrams are published with the original publications (17,18).…”

“…The cluster design was used to minimize contamination between groups. These trials were the Promoting Successful Weight Loss in Primary Care in Louisiana (PROPEL) trial (NCT02561221) (17) and the Rural Engagement in Primary Care for Optimizing Weight Reduction (REPOWER) trial (NCT02456636) (18). Efforts were made to harmonize the timeline, inclusion/exclusion criteria, and measurements between the two trials a priori.…”

Implementing texting programs in the P.O.W.E.R. (preventing obesity with eating right) medical group visit for weight loss

“…Delivering diet and physical activity interventions in group settings (not shared medical appointments) has shown to be effective in promoting weight loss at 12 months or greater 32,33 . A recent large study in rural primary care clinics found that in‐clinic group visits but not telephone‐based group visits, compared with in‐clinic individual visits, resulted in statistically significantly but modest weight loss at 24 months 34 . In our study, those who enrolled in the 20‐week texting program and those who did not enroll in any texting program had significant weight loss.…”