How Effective Is Obesity Management In Primary Care?
Thursday, December 11, 2014
Losing weight with behavioural interventions in the context of a clinical trial, where you are often dealing with volunteers who are generally provided interventions that are far better structured and standardised than we can ever hope to deliver in a primary care settings, tells us little about the effectiveness of such interventions in real life.
Now a paper by Tom Wadden and colleagues from the University of Pennsylvania, published in JAMA, presents a systematic review of the behavioral treatment of obesity in patients encountered in primary care settings as delivered by primary care practitioners working alone or with trained interventionists (eg, medical assistants, registered dietitians), or by trained interventionists working independently..
A search of the literature yielded 12 trials, involving 3893 participants, that met inclusion-exclusion criteria and prespecified quality ratings.
At 6-months weight changes in the intervention groups ranged from a loss of 0.3 kg to 6.6 kg compared to a gain of 0.9 kg to a loss of 2.0 kg in the control group.
As one may expect, interventions that prescribed both reduced energy intake (eg, ≥ 500 kcal/d) and increased physical activity (eg, ≥150 minutes a week of walking), with traditional behavioral therapy, generally produced larger weight loss than interventions without all three specific components.
Also, more treatment sessions (in person or by telephone) were associated with greater mean weight loss and likelihood of patients losing 5% or more of baseline weight.
Unfortunately, overtime, weight loss in both groups declined with longer follow-up (12-24 months).
Thus, the authors conclude that,
“Intensive behavioral counseling can induce clinically meaningful weight loss, but there is little research on primary care practitioners providing such care. The present findings suggest that a range of trained interventionists, who deliver counseling in person or by telephone, could be considered for treating overweight or obesity in patients encountered in primary care settings.”
Whether any of this is worth the cost and effort was not discussed. My guess is that to see greater success in primary care we need better treatments that move well beyond the rather simplistic ‘eat-less move-more’ paradigm.
@DrSharma
Edmonton, AB
Thursday, December 11, 2014
I remember my mother putting me in a behavioural support program when I was a teenager at the YMCA. All I can remember is how humiliating it was. I don’t think that the person leading the course was all that bad but just that I felt ashamed at having to go to the fat kid class. I remember sitting on the gym floor talking about healthy eating, but since I had a mother who was on the old diabetic diet (remember the blue book) we never ate unhealthy food at home. It seemed somehow unrelated to me in particular.
Thursday, December 11, 2014
What about other outcome parameters beside weightloss ?
Friday, December 12, 2014
Although I am somewhat hopeful (thanks to Dr. Sharma) that the medical system will change or catch on to what is needed, I think that the amount of care needed is just too much. For instance, every patient would need detailed program development, coaching, and continual follow up by various specialists and likely alternative care practitioners such as nutritionists, trainers, counselors, etc, etc. With so much focus on acute care for so many critical illnesses, I just don’t think such extensive and individual focused care will happen soon for obesity. The so called ‘easy solutions’ such as medication (if a safe and healthful solution can be found here) and relying on the diet and exercise industry may be what we have to accept.
Thursday, December 18, 2014
Hi Dr. Sharma,
I thnk medical doctors need to stop focusing on ‘weight loss” and instead focus on improving body composition-whch is what it is all about anyway. Actually, improved fitness is probabaly most important. Obesity is about too much fat specifically, not “weight” per se.
“Weight loss”, that is, patients who lost “weight” – it can be very, very UNsuccessful. Some poeple are fooling themselves. Having big saddle bag or love handles and reduced deltoid muscle and bony shoulders is not success at all- even if you lost “weight”. I know because I foolishly used to diet , do excessive cardio , not lift and this was the result.
Being a dieting “cardio rabbit” is the worst thing ever. And it is far wrose even for a woman.
Fat or muscle loss is “weight”, but sometimes over a long time one can overhaul their body composition leaving them not that much lighter but far better composition.
Even the way a normal person leans out looks much idfferent than an obesity sufferer who loses “weight.” They seem to go from big fatty legs to smaller fatty legs. Big piece of salami legs to a tinier piece of salami legs. There is obviously some type of dysregulaiton or fat cell hoarding going on compared to a never obese lean person who gains a bit of fat. Whereas a normal person gets much more toned in the legs and becomes more like human sirloin etc.
A lean person on Jupiter will “weigh” 600 pounds or so. LOL ! But he STILL will be lean. A severely obese person will not weigh more than about 100 pounds or so on the moon, yet still be very very fatty as far as body composition.
.
Lifting weights is the best thing I ever, ever did. To me it is the bedrock of what needs to be done first and foremost. Lifting weights is the closest thing to a fountain of youth we have.
I think BMI should be gotten rid of. And I am not just talking about muscular athletes. A person can have all different levels of body fat at various weights , or at the SAME weight OR even be leaner at a heavier weight.
Any honest appraisal of looking at one’s self will tell us a good deal. Whatever method is most accurate for determining ACTUAL body fat vs “weight” – actual body composition should be used and the BMI thrown in the trash. Scientists throw out things like yesterday’s newpaper when they find something far better and accurate.
Best wishes,
Raz