Obesity Treatment in Ambulatory Settings: What's Reasonable and Rational?
Disclosure: Dr. Harvey-Berino has NIH grants but otherwise has nothing to disclose.
Pub Date: Monday, Aug. 8, 2011
Author: Jean Harvey-Berino, PhD, RD
Affiliation: University of Vermont, Department of Nutrition and Food Sciences
Rao G, Burke LE, Spring BJ, et al; on behalf of the American Heart Association Obesity Committee of the Council on Nutrition, Physical Activity, and Metabolism, Council on Clinical Cardiology, Council on Cardiovascular and Stroke Nursing, Council on the Kidney in Cardiovascular Disease, and Stroke Council. New and emerging weight management strategies for busy ambulatory settings: a scientific statement from the American Heart Association. Circulation 2011: published online before print August 8, 2011, 10.1161/CIR.0b013e31822b9543.
Obesity is the greatest public health dilemma of our time, affecting 34% of all Americans and costing an estimated $147 billion; nearly 10% of all U.S. medical costs.[1,2] Thirty-four percent of adults over 20 years old are overweight, and no state has an obesity rate lower than 20%. Obesity is a complex disease with multiple etiologies that include both biological and behavioral factors. Unfortunately, it also is exceedingly difficult to treat, with few options currently available. Surgery has perhaps the best long-term outcomes but is an intensive and risky option only for the most obese patient. There are few medications to treat obesity, and they carry side effects and produce only modest increases in weight loss when compared with placebo. Behavioral interventions are currently considered the gold standard for obesity treatment,[6,7] typically producing a 9-kg weight loss over a 6-month period. However, the delivery of behavioral interventions is problematic. Trained interventionists are required, the participant burden can be high because the intervention is intensive - often requiring attendance at weekly meetings - and availability of high-quality programs is often restricted to larger metropolitan areas with teaching hospitals.
It comes as no surprise that physician practices and other ambulatory settings, busy or not, have struggled with how to manage obesity and overweight in their patients. Physicians do not have the time to spend with patients to elicit all of the information they need to do effective counseling and follow-up for weight issues, they don't get reimbursed for obesity treatment, and they often do not feel comfortable giving diet and exercise advice.[8,9] However, a study published more than 12 years ago by Galuska and colleagues  found that obese patients who received advice by their health care professional to lose weight were almost three times as likely to report trying to lose weight than those not receiving advice or similar counseling. Therefore, the development of weight management strategies for busy (or not busy) ambulatory settings is of critical importance. Patients appear to respond to advice received in a medical setting. The questions become how to best deliver that advice and what advice should be delivered? Can physicians be on the front line of obesity treatment, or can they only serve in an auxiliary role?
The paper published by Rao and colleagues  reviews only four published weight management interventions with physician involvement.[12-15] Three produced reasonable weight loss which exceeded that of a control condition [12,13,15] but all three used counseling and support services of trained nurses, counselors, or dietitians who delivered what was often a fairly intensive intervention. The Counterweight Programme  employed nurses to deliver six, 10- to 30-minute appointments over 3 months followed by quarterly visits; Feigenbaum et al.  had patients see a dietitian and physician every 2 weeks along with receiving orlistat, and Ely et al.  used trained counselors to deliver motivational interviewing sessions over the phone for 6 months. And although intensive, it's important to point out that none of these interventions produced weight losses similar to what is observed in the best behavior modification programs. In the end, the best strategy for ambulatory settings may be to deploy two out of the 5A's - ask and assess. Beyond that, referral may be a better option.
Although, as previously stated, high quality programs are difficult to find, the growth of telemedicine and the ubiquitous use of the Internet, smart phones, and social networking sites by nearly every pocket of humanity  may hold promise for the delivery of behavior modification interventions. There is emerging evidence that web-based weight loss programs can produce comparable weight losses to inperson treatment. They are also more cost-effective  and certainly easier to disseminate. Although the authors of the Rao paper correctly assert that there is still much to be learned about Internet-delivered interventions such as, who is best suited to participate and what web components are necessary for success, there have been significant advances in this field in a relatively short period of time. Web components necessary to produce meaningful weight loss are reviewed in Krukowski et al.  and Funk and colleagues. There are similarities in the findings, and it will come as no surprise that interactive website features that are dynamic and provide feedback are particularly helpful. The same can be said for early data on smart phone and personal digital assistant use to deliver weight management counseling.[22,23] With regard to obesity management, there appears to be no short-cut. The utilization of technology still requires the human touch.
As stated earlier, patients respond to physician advice to lose weight. Perhaps the greatest contribution health care professionals in an ambulatory setting can make is to heed the advice of Rao and colleagues and learn how to discuss weight issues in a nonjudgmental way using the right vocabulary. Because evidence suggests utilization of all 5 A's (ask, advise, assess, assist, and arrange) is likely impractical, other strategies need to be developed that enlist the health care team in a busy practice as part of the solution without having to shoulder the burden of delivering a complex, intensive, and lengthy intervention that they likely will not get reimbursed for in the end.
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-- The opinions expressed in this commentary are not necessarily those of the editors or of the American Heart Association