Can Bariatric Educators Have a Role in Primary Care?Wednesday, January 25, 2012
Readers may recall a recent post on a clinical trial by Wadden and colleagues on the feasibility of achieving clinically meaningful outcomes of ‘enhanced’ lifestyle counselling largely delivered by primary care practitioners with minimal training in obesity management. In that study, ‘health coaches’ (with no advanced expertise as one may expect from registered dieticians or exercise specialists), working under the guidance of a primary care physician, helped about 20-25% of patients achieve at least a 5% weight loss.
A paper by Sean Wharton and colleagues, published in the latest edition of the Canadian Family Physician, now presents ‘real-life’ data from a similar primary care approach in 2739 consenting patients attending an interdisciplinary obesity-management program in Burlington Ontario.
As described in the paper,
“The Wharton Medical Clinic (WMC) is an interdisciplinary bariatric clinic located in Hamilton and Burlington, Ont, which includes a team of physicians, behavioural therapists, dietitians, and nutritionists. The clinic operates under principles outlined in the Canadian clinical practice guidelines for the treatment of obesity, which recommend dietary, exercise, and behavioural interventions for weight loss, with meal replacement, pharmacotherapy, and surgery as adjunct therapies when indicated. Patient visits consist of services charged to the Ontario Health Insurance Plan, including physician visits, calorimetry, and diagnostic testing such as blood work and electrocardiography. Complementary services (drop-in visits in which patients weigh themselves and educational sessions) that are not charged to the Ontario Health Insurance Plan or to patients are also offered to allow for greater patient contact without increasing the cost to the health care system. As obesity is a chronic, relapsing medical condition, there is no defined program length.”
A key element of the program is the employment of ‘bariatric educators’, who have a university degree in nutrition, but no other formal training as health professionals. Under the guidance of the physicians, these bariatric educators deliver 20-minute educational sessions on nutrition and exercise to patients and monitor individualized weight-management strategies at each visit.
The paper presents the results of all 2739 patients as well as for the 1085 patients, who attended the clinic for at least 3 months, and the 389 patients, who attended for at least 6 months. The average weight loss in these groups were 2.3, 3.5, and 4.3 Kg, respectively.
Perhaps, more importantly, 17, 32, and 47% of patients achieved and maintained at least a 5% weight loss, whereas 4, 9, and 17% achieved a 10% weight loss, respectively.
Although these results may appear modest, it is important to note that these levels of adherence, retention, and ‘control’ are in fact very similar to what is seen with virtually every other chronic condition including hypertension, diabetes, or chronic respiratory disease and speaks to the general difficulties that many patients appear to have with the long-term adherence to chronic disease management programs in general, especially those requiring on-going frequent clinic visits.
Thus, as the authors note:
“As with many other chronic conditions, clinical goals and treatment outcomes for obesity management might not bring patients to “normal” levels. For example, the clinical goals for hypercholesteremia and hyperlipidemia, hypertension, and type 2 diabetes management do not return patients to levels observed in individuals without the conditions. In fact, up to two-thirds of patients are unable to meet clinical goal targets, highlighting the difficulty in managing chronic conditions. Thus, the proportion of participants achieving the targets of 5% to 10% weight loss at the WMC appears to be comparable with successes in the management of other metabolic conditions.”
This said, it is indeed notable that this ‘real-life example’ of a physician-run interdisciplinary publicly funded clinic (vs. the afore mentioned ‘clinical trial’ setting of the Wadden study) can help a substantial number of patients achieve clinically significant weight loss (almost 50% of patients who remained in the program for at least 6 months).
While this level of ‘success’ may be well below what most patients normally expect (for e.g. from a commercial ‘weight-loss’ program), the health benefits of modest ‘therapeutic’ weight loss are well recognized and may perhaps be better sustainable than the much larger short-term weight-loss promised and targeted in many commercially driven ‘wehght-loss’ programs.
Obviously, as the authors note, it will be important to determine the effectiveness of this program beyond six months.
Nevertheless, this ‘short-term’ real-life experience does provide some valuable insights:
For one, this paper demonstrates the potential value of bariatric educators (nutritionists), who provide education and dietary support.
As the authors note,
“The decision to engage nutritionists rather than registered dietitians in the program was based on the fact that although dietitians are highly qualified health professionals, their continuing engagement in a high-intensity program requiring ongoing follow-up visits is limited by availability and cost. In contrast, as demonstrated in this paper, bariatric educators, under the guidance of a physician, can provide an economical and effective approach to routine weight management in uncomplicated patients.”
“Given the important relationship between frequency of follow-up visits and maintenance of weight loss, it appears prudent to offer self-directed walk-in weigh-in sessions in an unintimidating environment, which increases patient contact with the clinic and serves as a regular reinforcement of behavioural change.”
Future studies will also need to determine improvements in other relevant health outcomes including comorbidities and quality of life as well as cost-effectiveness of this approach.
Nevertheless, these initial observations certainly appear promising and may provide a model for other primary care practices considering weight-management interventions in their patients.
Wharton S, Vanderlelie S, Sharma AM, Sharma S, & Kuk JL (2012). Feasibility of an interdisciplinary program for obesity management in Canada. Canadian family physician Medecin de famille canadien, 58 (1) PMID: 22267637