Enhanced Lifestyle Counseling for Obesity in Primary Care

As i have often noted before, the ultimate burden of delivering obesity management will fall on primary care practitioners (PCPs).

However, many PCPs shy away from providing these services due to lack of knowledge, lack of reimbursement or widely held beliefs about the modest outcomes of such services. In addition, practitioners (and patients) often cite the lack of access to specialized professionals (e.g. registered dietitians, psychologists, exercise specialists, etc.) as a limiting step in providing weight management in primary care.

Now, a paper by Tom Wadden and colleagues, just published in the New England Journal of Medicine, shows that clinically meaningful weight management can be provided in primary care settings by staff that has minimal training in obesity interventions.

For this study (Practice-based Opportunities for Weight Reduction Trial at the University of Pennsylvania or ‘POWER-UP’), a total of 390 obese adults in six primary care practices were randomized to one of three types of intervention:

1) Usual care, consisting of quarterly PCP visits that included education about weight management;

2) Brief lifestyle counseling, consisting of quarterly PCP visits combined with brief monthly sessions with lifestyle coaches who instructed participants about behavioral weight control;

3) Enhanced brief lifestyle counseling, which provided the same care as described for the previous intervention but included meal replacements (SlimFast) or weight-loss medication (sibutramine or orlistat).

Over 85% of participants completed the 2-year trial, at which time, the mean weight loss with usual care, brief lifestyle counseling, and enhanced brief lifestyle counseling was 1.7, 2.9, and 4.6 kg, respectively.

Initial weight decreased at least 5% in 21.5%, 26.0%, and 34.9% of the participants in the three groups, respectively.

While these reductions in body weight, are certainly modest, the key point of interest to me is that the brief lifestyle counselling interventions were delivered in 10 to 15 minutes of monthly encounters with an auxiliary health care provider (medical assistant), referred to as a ‘lifestyle coach, who was trained and certified to deliver assessment and advise based on a review of participants’ recording of food intake, physical activity, and other goals.

Importantly, none of these PCPs or ‘lifestyle’ coaches had any prior training or experience in weight management. In fact, their only qualification for providing weight counselling consisted of study staff provided 6 to 8 hours of training to PCPs and lifestyle coaches. Recertification was provided every 6 months and throughout the trial, study staff met with PCPs and coaches for 30 to 60 mins to review protocol implementation.

Thus, these results were achieved by PCP staff that underwent minimal training in weight management and certainly had no ‘advanced’ professional expertise (e.g. that of a registered dietitian or certified exercise physiologist).

As the authors point out, this study certainly shows that even the most minimal intervention provided in this study by PCPs and ‘health coaches’ could achieve a clinically meaningful 5% weight loss in about 20-25% of their patients, certainly not a number to be lightly dismissed given the evidence that a 5% weight loss may be enough to decrease the risk of type 2 diabetes by 60% (indeed, such ‘control’ rates are not too different from those of many other chronic conditions in primary care settings).

While the paper does not discuss actual costs of this interventions (or its long-term cost-effectiveness), the results certainly suggest that weight management in primary care could be delivered at a reasonable and sustainable cost, even with very limited resources or training.

On the other hand, I would be tempted to suggest that any ‘lifestyle’ intervention that is largely based on a ‘behavioural’ rather than an ‘etiological’ paradigm is always likely to produce modest outcomes (that most patients are unlikely to sustain).

While simple advise and reinforcement can certainly be delivered with some basic training in ‘coaching’ techniques, I would presume that interventions that specifically address the ‘whys’ underlying the relevant behaviours may well require greater diagnostic competencies and expertise (and possibly different management strategies).

Thus, I continue to be wary of obesity studies that recruit ‘all comers’ irrespective of potential differences in aetiology – after all, eating too much is a ‘symptom’ not a ‘diagnosis’.

AMS
Toronto, Ontario

Wadden TA, Volger S, Sarwer DB, Vetter ML, Tsai AG, Berkowitz RI, Kumanyika S, Schmitz KH, Diewald LK, Barg R, Chittams J, & Moore RH (2011). A Two-Year Randomized Trial of Obesity Treatment in Primary Care Practice. The New England journal of medicine PMID: 22082239