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Evaluation and Treatment of Obesity in Primary Care

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Treatment of the Obese Patient

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Abstract

This chapter reviews the results of randomized trials of the treatment of obesity in primary care. The results are described in the context of the recent decision by CMS (Center for Medicare and Medicaid Services) to reimburse primary care providers for a schedule of visits that meets criteria for high-intensity obesity treatment, as is recommended by the US Preventive Services Task Force. We found that trials in which counseling was provided by PCPs themselves or other office staff typically led to modest weight loss (1–3 kg), likely a result of low-to-moderate-intensity intervention. Trials that provided multimodality treatment, combining counseling with pharmacotherapy or meal replacements, more often achieved clinically significant weight loss (≥5 % of starting weight). Remotely delivered interventions (telephone and web-based) yielded modest weight loss in two studies involving low-income populations, but produced higher weight losses in two trials involving more socioeconomically diverse populations. In the single trial that most closely approximated the schedule of visits currently reimbursed by CMS, dietitians as counselors achieved more than twice the weight loss achieved by PCPs (with patients using meal replacements in both groups). Further study is needed to determine how best to deliver high-intensity counseling to obese patients in primary care settings, including economic analyses to determine the most efficient ways to offer treatment.

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References

  1. Tsai AG, Abbo ED, Ogden LG. The time burden of overweight and obesity in primary care. BMC Health Serv Res. 2011;11:191.

    Article  PubMed Central  PubMed  Google Scholar 

  2. Center for Medicare and Medicaid Services. Decision memo for intensive behavioral therapy for obesity (CAG-00423N). 2011. http://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?&NcaName=IntensiveBehavioralTherapyforObesity&bc=ACAAAAAAIAAA&NCAId=253&. Accessed 10 Dec 2011.

  3. Flegal KM, Carroll MD, Kit BK, Ogden CL. Prevalence of obesity and trends in the distribution of body mass index among US adults, 1999–2010. JAMA. 2012;307(5):491–7.

    Article  PubMed  Google Scholar 

  4. National Heart Lung and Blood Institute (NHLBI). Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults—the evidence report. National Institutes of Health. Obesity Res. 1998;6 Suppl 2:51S–209.

    Google Scholar 

  5. Wing RR, Lang W, Wadden TA, et al. Benefits of modest weight loss in improving cardiovascular risk factors in overweight and obese individuals with type 2 diabetes. Diabetes Care. 2011;34(7):1481–6.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  6. Knowler WC, Barrett-Connor E, Fowler SE, et al. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. 2002;346(6):393–403.

    Article  CAS  PubMed  Google Scholar 

  7. Wadden TA, Webb VL, Moran CH, Bailer BA. Lifestyle modification for obesity: new developments in diet, physical activity, and behavior therapy. Circulation. 2012;125(9):1157–70.

    Article  PubMed Central  PubMed  Google Scholar 

  8. Moyer VA, on behalf of the USPSTF. Screening for and management of obesity in adults: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2012;157(5):373–8.

    PubMed  Google Scholar 

  9. McTigue KM, Harris R, Hemphill B, et al. Screening and interventions for obesity in adults: summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2003;139(11):933–49.

    Article  PubMed  Google Scholar 

  10. Wadden TA, Volger S, Tsai AG, et al. Managing obesity in primary care practice: an overview with perspective from the POWER-UP study. Int J Obes (Lond). 2013;37 Suppl 1:S3–11.

    Article  PubMed Central  Google Scholar 

  11. Carvajal R, Wadden TA, Tsai AG, Peck K, Moran CH. Managing obesity in primary care practice: a narrative review. Ann N Y Acad Sci. 2013;1281:191–206.

    Article  PubMed Central  PubMed  Google Scholar 

  12. National Heart Lung and Blood Institute (NHLBI) and North American Association for the Study of Obesity (NAASO). The practical guide: identification, evaluation, and treatment of overweight and obesity in adults. NIH Publication 02-4084; 2000.

    Google Scholar 

  13. Church TS, Blair SN, Cocreham S, et al. Effects of aerobic and resistance training on hemoglobin A1c levels in patients with type 2 diabetes: a randomized controlled trial. JAMA. 2010;304(20):2253–62.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  14. Donnelly JE, Blair SN, Jakicic JM, et al. American College of Sports Medicine Position Stand. Appropriate physical activity intervention strategies for weight loss and prevention of weight regain for adults. Med Sci Sports Exerc. 2009;41(2):459–71.

    Article  PubMed  Google Scholar 

  15. Wing R. Behavioral treatment of obesity. In: Wadden TA, Stunkard AJ, editors. Handbook of obesity treatment. New York: Guilford; 2002. p. 301–16.

    Google Scholar 

  16. Leblanc ES, O’Connor E, Whitlock EP, Patnode CD, Kapka T. Effectiveness of primary care-relevant treatments for obesity in adults: a systematic evidence review for the U.S. Preventive Services Task Force. Ann Intern Med. 2011;155(7):434–47.

    Article  PubMed  Google Scholar 

  17. Kushner RF. Barriers to providing nutrition counseling by physicians: a survey of primary care practitioners. Prev Med. 1995;24(6):546–52.

    Article  CAS  PubMed  Google Scholar 

  18. Tsai AG, Mitchell NS. Can we talk about your weight for a few minutes, Mr. Jones? Virtual Mentor. 2010;12(4):299–304.

    Article  PubMed  Google Scholar 

  19. Simkin-Silverman LR, Wing RR. Management of obesity in primary care. Obes Res. 1997;5(6):603–12.

    Article  CAS  PubMed  Google Scholar 

  20. Serdula MK, Khan LK, Dietz WH. Weight loss counseling revisited. JAMA. 2003;289(14):1747–50.

    Article  PubMed  Google Scholar 

  21. Tsai AG, Wadden TA. Treatment of obesity in primary care practice in the United States: a systematic review. J Gen Intern Med. 2009;24(9):1073–9.

    Article  PubMed Central  PubMed  Google Scholar 

  22. Wadden TA, West DS, Delahanty L, et al. The Look AHEAD study: a description of the lifestyle intervention and the evidence supporting it. Obesity. 2006;14(5):737–52.

    Article  PubMed  Google Scholar 

  23. Tsai AG, Fabricatore AN, Wadden TA, et al. Readiness redefined: a behavioral task during screening predicted 1-year weight loss in the Look AHEAD study. Obesity. 2014;22(4):1016–23.

    Google Scholar 

  24. Wadden TA, Sarwer DB. Behavioral assessment of candidates for bariatric surgery: a patient-oriented approach. Obesity. 2006;14 Suppl 2:53S–62.

    Article  PubMed  Google Scholar 

  25. Bray GA, Ryan DH. Medical therapy for the patient with obesity. Circulation. 2012;125(13):1695–703.

    Article  PubMed  Google Scholar 

  26. Digenio AG, Mancuso JP, Gerber RA, Dvorak RV. Comparison of methods for delivering a lifestyle modification program for obese patients: a randomized trial. Ann Intern Med. 2009;150(4):255–62.

    Article  PubMed  Google Scholar 

  27. Wadden TA, Berkowitz RI, Womble LG, et al. Randomized trial of lifestyle modification and pharmacotherapy for obesity. N Engl J Med. 2005;353(20):2111–20.

    Article  CAS  PubMed  Google Scholar 

  28. Tsai AG, Wadden TA, Rogers MA, Day SC, Moore RH, Islam BJ. A primary care intervention for weight loss: results of a randomized controlled pilot study. Obesity. 2010;18(8):1614–8.

    Article  PubMed  Google Scholar 

  29. Weinstock RS, Trief PM, Cibula D, Morin PC, Delahanty LM. Weight loss success in metabolic syndrome by telephone interventions: results from the SHINE study. J Gen Intern Med. 2013;28:1620–8.

    Article  PubMed  Google Scholar 

  30. Dansinger ML, Tatsioni A, Wong JB, Chung M, Balk EM. Meta-analysis: the effect of dietary counseling for weight loss. Ann Intern Med. 2007;147(1):41–50.

    Article  PubMed  Google Scholar 

  31. Rao G, Burke LE, Spring BJ, et al. New and emerging weight management strategies for busy ambulatory settings: a scientific statement from the American Heart Association endorsed by the Society of Behavioral Medicine. Circulation. 2011;124(10):1182–203.

    Article  PubMed  Google Scholar 

  32. ter Bogt NC, Bemelmans WJ, Beltman FW, Broer J, Smit AJ, van der Meer K. Preventing weight gain by lifestyle intervention in a general practice setting: three-year results of a randomized controlled trial. Arch Intern Med. 2011;171(4):306–13.

    PubMed  Google Scholar 

  33. Cohen MD, D’Amico FJ, Merenstein JH. Weight reduction in obese hypertensive patients. Fam Med. 1991;23(1):25–8.

    CAS  PubMed  Google Scholar 

  34. Ockene IS, Hebert JR, Ockene JK, et al. Effect of physician-delivered nutrition counseling training and an office-support program on saturated fat intake, weight, and serum lipid measurements in a hyperlipidemic population: Worcester Area Trial for Counseling in Hyperlipidemia (WATCH). Arch Intern Med. 1999;159(7):725–31.

    Article  CAS  PubMed  Google Scholar 

  35. Martin PD, Dutton GR, Rhode PC, Horswell RL, Ryan DH, Brantley PJ. Weight loss maintenance following a primary care intervention for low-income minority women. Obesity. 2008;16(11):2462–7.

    Article  PubMed Central  PubMed  Google Scholar 

  36. Christian JG, Bessesen DH, Byers TE, Christian KK, Goldstein MG, Bock BC. Clinic-based support to help overweight patients with type 2 diabetes increase physical activity and lose weight. Arch Intern Med. 2008;168(2):141–6.

    Article  PubMed  Google Scholar 

  37. Christian JG, Byers TE, Christian KK, et al. A computer support program that helps clinicians provide patients with metabolic syndrome tailored counseling to promote weight loss. J Am Diet Assoc. 2011;111(1):75–83.

    Article  PubMed  Google Scholar 

  38. Hamman RF, Wing RR, Edelstein SL, et al. Effect of weight loss with lifestyle intervention on risk of diabetes. Diabetes Care. 2006;29(9):2102–7.

    Article  PubMed Central  PubMed  Google Scholar 

  39. Ashley JM, St Jeor ST, Schrage JP, et al. Weight control in the physician’s office. Arch Intern Med. 2001;161(13):1599–604.

    Article  CAS  PubMed  Google Scholar 

  40. Brownell KD. The LEARN program for weight control: lifestyle, exercise, attitudes, relationships, nutrition. Dallas: American Health Publishing; 1998.

    Google Scholar 

  41. Heymsfield SB, van Mierlo CA, van der Knaap HC, Heo M, Frier HI. Weight management using a meal replacement strategy: meta and pooling analysis from six studies. Int J Obes Relat Metab Disord. 2003;27(5):537–49.

    Article  CAS  PubMed  Google Scholar 

  42. Apfelbaum M, Vague P, Ziegler O, Hanotin C, Thomas F, Leutenegger E. Long-term maintenance of weight loss after a very-low-calorie diet: a randomized blinded trial of the efficacy and tolerability of sibutramine. Am J Med. 1999;106(2):179–84.

    Article  CAS  PubMed  Google Scholar 

  43. Hauptman J, Lucas C, Boldrin MN, Collins H, Segal KR. Orlistat in the long-term treatment of obesity in primary care settings. Arch Fam Med. 2000;9(2):160–7.

    Article  CAS  PubMed  Google Scholar 

  44. Poston WS, Haddock CK, Pinkston MM, et al. Evaluation of a primary care-oriented brief counselling intervention for obesity with and without orlistat. J Intern Med. 2006;260(4):388–98.

    Article  CAS  PubMed  Google Scholar 

  45. James WP, Caterson ID, Coutinho W, et al. Effect of sibutramine on cardiovascular outcomes in overweight and obese subjects. N Engl J Med. 2010;363(10):905–17.

    Article  CAS  PubMed  Google Scholar 

  46. Garvey WT, Ryan DH, Look M, et al. Two-year sustained weight loss and metabolic benefits with controlled-release phentermine/topiramate in obese and overweight adults (SEQUEL): a randomized, placebo-controlled, phase 3 extension study. Am J Clin Nutr. 2012;95(2):297–308.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  47. Smith SR, Weissman NJ, Anderson CM, et al. Multicenter, placebo-controlled trial of lorcaserin for weight management. N Engl J Med. 2010;363(3):245–56.

    Article  CAS  PubMed  Google Scholar 

  48. Wadden TA, Volger S, Sarwer DB, et al. A two-year randomized trial of obesity treatment in primary care practice. N Engl J Med. 2011;365(21):1969–79.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  49. Kumanyika SK, Fassbender JE, Sarwer DB, et al. One-year results of the Think Health! study of weight management in primary care practices. Obesity. 2012;20(6):1249–57.

    Article  PubMed  Google Scholar 

  50. Ma J, Yank V, Xiao L, et al. Translating the Diabetes Prevention Program lifestyle intervention for weight loss into primary care: a randomized trial. JAMA. 2013;173(2):113–21.

    Google Scholar 

  51. Ryan DH, Johnson WD, Myers VH, et al. Nonsurgical weight loss for extreme obesity in primary care settings: results of the Louisiana Obese Subjects Study. Arch Intern Med. 2010;170(2):146–54.

    Article  CAS  PubMed  Google Scholar 

  52. Pinto AM, Fava JL, Hoffmann DA, Wing RR. Combining behavioral weight loss treatment and a commercial program: a randomized clinical trial. Obesity. 2013;21(4):673–80.

    Article  PubMed Central  PubMed  Google Scholar 

  53. Donnelly JE, Smith BK, Dunn L, et al. Comparison of a phone vs clinic approach to achieve 10 % weight loss. Int J Obes (Lond). 2007;31(8):1270–6.

    Article  CAS  Google Scholar 

  54. Perri MG, Limacher MC, Durning PE, et al. Extended-care programs for weight management in rural communities: the treatment of obesity in underserved rural settings (TOURS) randomized trial. Arch Intern Med. 2008;168(21):2347–54.

    Article  PubMed Central  PubMed  Google Scholar 

  55. Appel LJ, Clark JM, Yeh HC, et al. Comparative effectiveness of weight-loss interventions in clinical practice. N Engl J Med. 2011;365(21):1959–68.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  56. Haapala I, Barengo NC, Biggs S, Surakka L, Manninen P. Weight loss by mobile phone: a 1-year effectiveness study. Public Health Nutr. 2009;12(12):2382–91.

    Article  PubMed  Google Scholar 

  57. Tate DF, Jackvony EH, Wing RR. Effects of Internet behavioral counseling on weight loss in adults at risk for type 2 diabetes: a randomized trial. JAMA. 2003;289(14):1833–6.

    Article  PubMed  Google Scholar 

  58. Harvey-Berino J, West D, Krukowski R, et al. Internet delivered behavioral obesity treatment. Prev Med. 2010;51(2):123–8.

    Article  PubMed Central  PubMed  Google Scholar 

  59. Logue E, Sutton K, Jarjoura D, Smucker W, Baughman K, Capers C. Transtheoretical model-chronic disease care for obesity in primary care: a randomized trial. Obes Res. 2005;13(5):917–27.

    Article  PubMed  Google Scholar 

  60. Ely AC, Banitt A, Befort C, et al. Kansas primary care weighs in: a pilot randomized trial of a chronic care model program for obesity in 3 rural Kansas primary care practices. J Rural Health. 2008;24(2):125–32.

    Article  PubMed  Google Scholar 

  61. Bennett GG, Herring SJ, Puleo E, Stein EK, Emmons KM, Gillman MW. Web-based weight loss in primary care: a randomized controlled trial. Obesity. 2010;18(2):308–13.

    Article  PubMed Central  PubMed  Google Scholar 

  62. Bennett GG, Warner ET, Glasgow RE, et al. Obesity treatment for socioeconomically disadvantaged patients in primary care practice. Arch Intern Med. 2012;172:565–74.

    Article  PubMed Central  PubMed  Google Scholar 

  63. McTigue KM, Conroy MB, Hess R, et al. Using the internet to translate and evidence-based lifestyle intervention into practice. Telemed J E Health. 2009;15(9):851–8.

    Article  PubMed  Google Scholar 

  64. Renjilian DA, Perri MG, Nezu AM, McKelvey WF, Shermer RL, Anton SD. Individual versus group therapy for obesity: effects of matching participants to their treatment preferences. J Consult Clin Psychol. 2001;69(4):717–21.

    Article  CAS  PubMed  Google Scholar 

  65. Tsai AG, Wadden TA. Systematic review: an evaluation of major commercial weight loss programs in the United States. Ann Intern Med. 2005;142(1):56–66.

    Article  PubMed  Google Scholar 

  66. Rock CL, Flatt SW, Sherwood NE, Karanja N, Pakiz B, Thomson CA. Effect of a free prepared meal and incentivized weight loss program on weight loss and weight loss maintenance in obese and overweight women: a randomized controlled trial. JAMA. 2010;304(16):1803–10.

    Article  CAS  PubMed  Google Scholar 

  67. Rock CL, Pakiz B, Flatt SW, Quintana EL. Randomized trial of a multifaceted commercial weight loss program. Obesity. 2007;15(4):939–49.

    Article  PubMed  Google Scholar 

  68. Foster GD, Borradaile KE, Vander Veur SS, et al. The effects of a commercially available weight loss program among obese patients with type 2 diabetes: a randomized study. Postgrad Med. 2009;121(5):113–8.

    Article  PubMed  Google Scholar 

  69. Mitchell NS, Dickinson LM, Kempe A, Tsai AG. Determining the effectiveness of Take Off Pounds Sensibly (TOPS), a nationally available nonprofit weight loss program. Obesity. 2011;19(3):568–73.

    Article  PubMed  Google Scholar 

  70. Jebb SA, Ahern AL, Olson AD, et al. Primary care referral to a commercial provider for weight loss treatment versus standard care: a randomised controlled trial. Lancet. 2011;378(9801):1485–92.

    Article  PubMed Central  PubMed  Google Scholar 

  71. Jolly K, Lewis A, Beach J, et al. Comparison of range of commercial or primary care led weight reduction programmes with minimal intervention control for weight loss in obesity: lighten Up randomised controlled trial. BMJ. 2011;343:d6500.

    Article  PubMed Central  PubMed  Google Scholar 

  72. Tsai AG, Wadden TA. The evolution of very-low-calorie diets: an update and meta-analysis. Obesity. 2006;14(8):1283–93.

    Article  PubMed  Google Scholar 

  73. Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA. 2004;292(14):1724–37.

    Article  CAS  PubMed  Google Scholar 

  74. Maggard MA, Shugarman LR, Suttorp M, et al. Meta-analysis: surgical treatment of obesity. Ann Intern Med. 2005;142(7):547–59.

    Article  PubMed  Google Scholar 

  75. Christou NV, Look D, Maclean LD. Weight gain after short- and long-limb gastric bypass in patients followed for longer than 10 years. Ann Surg. 2006;244(5):734–40.

    Article  PubMed Central  PubMed  Google Scholar 

  76. Carlin AM, Zeni TM, English WJ, et al. The comparative effectiveness of sleeve gastrectomy, gastric bypass, and adjustable gastric banding procedures for the treatment of morbid obesity. Ann Surg. 2013;257(5):791–7.

    Article  PubMed  Google Scholar 

  77. Vetter ML, Cardillo S, Rickels MR, Iqbal N. Narrative review: effect of bariatric surgery on type 2 diabetes mellitus. Ann Intern Med. 2009;150(2):94–103.

    Article  PubMed  Google Scholar 

  78. Longitudinal Assessment of Bariatric Surgery Consortium. Perioperative safety in the longitudinal assessment of bariatric surgery. N Engl J Med. 2009;361(5):445–54.

    Article  Google Scholar 

  79. Flum DR, Salem L, Elrod JA, Dellinger EP, Cheadle A, Chan L. Early mortality among Medicare beneficiaries undergoing bariatric surgical procedures. JAMA. 2005;294(15):1903–8.

    Article  CAS  PubMed  Google Scholar 

  80. Ackermann RT, Finch EA, Brizendine E, Zhou H, Marrero DG. Translating the Diabetes Prevention Program into the community. The DEPLOY Pilot Study. Am J Prev Med. 2008;35(4):357–63.

    Article  PubMed Central  PubMed  Google Scholar 

  81. McQuigg M, Brown J, Broom J, et al. Empowering primary care to tackle the obesity epidemic: the Counterweight Programme. Eur J Clin Nutr. 2005;59 Suppl 1:S93–100; discussion S101.

    Google Scholar 

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Acknowledgments

Preparation of this article was supported, in part, by grant K24-DK065018 from the National Institute of Diabetes Digestive and Kidney Disease, grant U01-HL087072 from the National Heart, Lung, and Blood Institute, and grant 10SDG2610292 from the American Heart Association.

Thomas Wadden serves on advisory boards for Novo Nordisk and Orexigen Therapeutics, each of which is developing weight loss medications. None of the other authors has any potential conflicts of interest to disclose.

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Authors and Affiliations

  1. Division of General Internal Medicine and Anschutz Center for Health and Wellness, University of Colorado School of Medicine, 12348 E. Montview Ave, Room 4108, Aurora, CO, 80045, USA

    Adam Gilden Tsai M.D., M.S.C.E.

  2. Center for Weight and Eating Disorders, Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA

    Raymond Carvajal Psy.D., Patricia S. Hong B.A., Amber D. Baxley B.A. & Thomas A. Wadden Ph.D.

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  1. Adam Gilden Tsai M.D., M.S.C.E.
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Correspondence to Adam Gilden Tsai M.D., M.S.C.E. .

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Editors and Affiliations

  1. Department of Medicine, Division of Endocrinology, Metabolism, and Molecular Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA

    Robert F. Kushner

  2. Endocrinology, University of Colorado School of Medicine, Denver, Colorado, USA

    Daniel H. Bessesen

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Tsai, A.G., Carvajal, R., Hong, P.S., Baxley, A.D., Wadden, T.A. (2014). Evaluation and Treatment of Obesity in Primary Care. In: Kushner, R., Bessesen, D. (eds) Treatment of the Obese Patient. Springer, New York, NY. https://doi.org/10.1007/978-1-4939-1203-2_19

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