Managing Obesity in Primary Care – What Works and What Doesn’tMonday, September 14, 2009
Given that obesity affects millions of people, is the root cause of a laundry list of health problems, and requires long-term management, there is really no option but to manage patients in primary care.
But how effective is this?
This was now the topic of a systemic review by Adam Tsai and Thomas Wadden from the University of Colorado, just published in the Journal of General Internal Medicine.
This review examines the results of randomized controlled trials in which behavioral weight loss interventions, used alone or with pharmacotherapy, were provided by a primary care provider (PCP) in primary care settings.
An extensive literature search identified ten trials that met the inclusion criteria. They included studies on PCP counseling alone, PCP counseling + pharmacotherapy, and “collaborative” obesity care (treatment delivered by a non-physician provider).
Weight losses in the active treatment arms of these categories of studies ranged from 0.1 to 2.3 kg, 1.7 to 7.5 kg, and 0.4 to 7.7 kg, respectively.
Given the limited success of most strategies, the authors conclude that current evidence does not support the sole use of low- or moderate-intensity counseling to achieve clinically meaningful weight loss.
Based on these studies it appears that only when PCP counseling is combined with pharmacotherapy or intensive counseling (from a dietitian or nurse) plus meal replacements, do patients stand a chance of actually achieving this goal.
This study should not come as a surprise to anyone and should certainly not be used as an argument against addressing weight management in primary care.
As blogged before – success in weight management does not start with weight loss – it starts with limiting weight gain!
The fact that a team approach is better than simply having a doctor (most of who have minimal training in weight management, if at all) tell their patients to lose weight is not news.
The notion that most patients will need more than lifestyle counseling and may have to resort to medications and/or partial meal replacement strategies is, I believe, becoming increasingly obvious.
Here, as blogged before, is what I believe PCPs can do for obesity management in primary care – not all of it based on randomised trials but just on common sense, my personal (albeit anecdotal) experience, and of course my interpretation of the literature.