PHILADELPHIA - An important addition to the "eat less, move more" strategy for weight loss lies in behavioral counseling to achieve these goals. But research on how primary care practitioners can best provide behavioral weight loss counseling to obese patients in their practices -- as encouraged by the Centers for Medicare and Medicaid Services (CMS) -- remains slim, according to a systematic review of this topic published today in JAMA. The study was led by researchers from the Perelman School of Medicine at the University of Pennsylvania.
"After an exhaustive search, we found only 12 high quality randomized controlled trials that examined the behavioral treatment of obesity in patients encountered in primary care settings," said Thomas A. Wadden, PhD, director of Penn's Center for Weight and Eating Disorders and the review's lead author. "Of those, only two studies identified counseling interventions that produced an average loss of at least five percent of initial body weight, an amount likely to improve weight-related health complications."
The researchers initiated their review in response to two important policy developments in weight management. In 2003 (and again in 2012), the U.S. Preventive Services Task Force recommended that primary care practitioners screen all adults for obesity and offer or refer affected individuals to an intensive, multicomponent weight loss intervention (typically aimed at modifying diet, physical activity and related behaviors) . In 2011, CMS approved payment for intensive behavioral weight loss counseling, consisting of approximately 14 face-to-face, 10 to 15 minute sessions over six months, for obese individuals treated in primary care settings.
"The CMS's decision to reimburse the cost of intensive behavioral counseling for Medicare-eligible patients was an important step in advancing the treatment of a disease that has long been overlooked," said Adam Tsai, MD, a co-author of the review and an internal medicine and obesity specialist at Kaiser Permanente in Denver.
However, the researchers did not find any studies in which primary care practitioners delivered behavioral counseling following the exact CMS guidelines. Among other requirements, these guidelines specify that behavioral weight loss counseling must be provided by CMS-defined practitioners, who currently are limited to physicians, nurse practitioners, clinical nurse specialists and physician assistants. Counseling potentially may be provided by auxiliary health professionals, such as registered dietitians, who work in the same physical setting as the primary care practitioners and are directly supervised by them. However, no such studies were identified in the review. Auxiliary health providers cannot provide weight loss counseling independently of primary care providers under current CMS guidelines.
The review, which included a total of 3,893 participants, found that behavioral counseling interventions that included both a reduced-calorie diet (to decrease intake by 500 or more calories per day) and a program of physical activity (at least 150 minutes or more per week of walking or similar behavior) generally produced greater weight loss than programs that did not include both of these specific diet and physical activity prescriptions. This finding is consistent with recommendations for comprehensive behavioral weight loss counseling provided by the Guidelines for the Management of Overweight and Obesity in Adults, issued jointly in 2013 by the American Heart Association, the American College of Cardiology and the Obesity Society.
The provision of more counseling visits during the first six months (for example, 15 sessions versus eight) also tended to be associated with greater weight loss, "although, we did not identify enough studies of similar design to formally test this relationship," said Meghan Butryn, PhD, a study co-author and associate professor of psychology at Drexel University in Philadelphia. "However, previous analyses of weight loss interventions conducted in academic centers, rather than in primary care settings, have found that more counseling sessions are associated with greater weight loss."
In the study that perhaps came closest to meeting the CMS requirements, a registered dietitian and an exercise specialist jointly provided 12 weekly, face-to-face group counseling sessions, followed by twice monthly telephone or e-mail contacts, to overweight and obese patients in a large primary practice. Participants lost an average of 15 pounds in six months, and nearly two-thirds lost five percent or more of their initial weight. "These are impressive results for the number of treatment visits provided, and weight losses were well maintained over two years," said Wadden.
Additional studies reviewed by the authors examined the use as interventionists of medical assistants, community health educators, and individuals with other professional backgrounds, all of whom were trained to deliver behavioral counseling. The authors concluded that further research is needed to evaluate the effectiveness and cost of having behavioral counseling delivered by CMS-designated primary care practitioners, as compared with registered dietitians, nurses, health counselors, and other auxiliary health professionals. In addition, recent randomized controlled trials, including one included in the review, have shown that trained interventionists can effectively deliver weight loss counseling by telephone and/or Internet. "I think we will see increasing use of remotely-delivered weight loss counseling, whether by telephone, smart phones, the Internet or other digital approaches," Tsai said. "Telephone-delivered counseling, provided by counselors from a patient's primary care practice, or by a trained interventionist from a disease management call center, is likely to be more convenient and less costly for patients and potentially for health care providers and insurers."
The researchers concluded that physicians and other primary care practitioners could readily learn to provide intensive behavioral counseling, like the other trained interventionists identified in the review. However, ever-increasing demands on practitioners' time may favor their referring patients for behavioral weight loss counseling rather than trying to provide such care themselves, an option included by the U.S. Preventive Services Task Force. "A variety of trained interventions potentially could deliver effective, evidence-based weight loss counseling to the millions of Americans who would benefit from it, said Wadden. "Primary care practitioners cannot be expected to go it alone in reducing our nation's waistline."
Editor's Note: The other Penn co-author on the paper was Patricia Hong, BS, a former research coordinator at Penn's Center for Weight and Eating Disorders. Wadden's work on this study was supported, in part, by a grant from the National Institute of Diabetes and Digestive and Kidney Diseases (DK-65018).
Wadden serves on advisory boards for Nutrisystem, Novo Nordisk, Orexigen and Shire Pharmaceuticals; he has received grant support, on behalf of the University of Pennsylvania, from the first three organizations and from Weight Watchers International. He also serves on an external advisory board for Johns Hopkins University concerning a proprietary weight loss program (Innergy), developed by Johns Hopkins University and Healthways.
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