Obesity Treatment in Ambulatory Settings: What's Reasonable and Rational?

Updated:May 27,2014

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.

Article Text

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%.[1] Obesity is a complex disease with multiple etiologies that include both biological and behavioral factors.[3] 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.[4] There are few medications to treat obesity, and they carry side effects and produce only modest increases in weight loss when compared with placebo.[5] 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 [10] 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 [11] 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 [12] employed nurses to deliver six, 10- to 30-minute appointments over 3 months followed by quarterly visits; Feigenbaum et al. [13] had patients see a dietitian and physician every 2 weeks along with receiving orlistat, and Ely et al. [15] 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 [16] 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.[17] They are also more cost-effective [18] 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. [19] and Funk and colleagues.[20] 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.[21] 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.[10] 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,[24] 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.


  1. Centers for Disease Control and Prevention. Prevalence of overweight, obesity, and extreme obesity among adults: United States, trends 1960-1962 through 2007-2008. Accessed July 28, 2011.
  2. Trogdon JG, Finkelstein EA, Feagan CW, Cohen JW. State- and payer-specific estimates of annual medical expenditures attributable to obesity. Obesity. 2011 Jun 16. [Epub ahead of print]
  3. Weinsier RL, Hunter GR, Heini AF, et al. The etiology of obesity: relative contribution of metabolic factors, diet, and physical activity. Amer J Med. 1998;105(2):145-150.
  4. Buchwald H, Estok R, Fahrbach K, et al. Weight and type 2 diabetes after bariatric surgery: systematic review and meta-analysis. Amer J Med. 2009;e5:248-256.
  5. Yanovski S, Yanovski JA. Obesity. N Engl J Med. 2002;346:591-602.
  6. Knowler WC, Barrett-Connor E, Fowler SE, et al; Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. 2002;346(6):393-403.
  7. Wadden TA, Neiberg RH, Wing RR, et al. Four-year weight losses in the look ahead study: factors associated with long-term success. Obesity. 2011 [Epub ahead of print]
  8. Kushner RF. Barriers to providing nutrition counseling by physicians. Prev Med. 1995;24:546-552.
  9. Yeager KK, Donehoo RS, Macera CA, et al. Health promotion practices among physicians. Am J Prev Med. 1996;12:238-241.
  10. Galuska DA, Will JC, Serdula MK, Ford ES. Are health care professionals advising obese patients to lose weight? JAMA. 1999;282:1576-1578.
  11. Rao G, Burke LE, Spring B, et al. New and emerging weight management strategies for busy ambulatory settings. 2011.
  12. Laws R, Counterweight Project Team. A new evidence based model for weight management in primary care: the Counterweight Programme. J Hum Nutr Diet. 2004;17(3):191-208.
  13. Feigenbaum A, Pasternak S, Zusk E, et al. Influence of intense multi-disciplinary follow-up and orlistat on weight reduction in a primary care setting. BMC Fam Pract. 2005;6(1):5.
  14. Logue E, Sutton K, Jarjoura D, et al. Transtheoretical model-chronic disease care for obesity in primary care: a randomized trial. Obes Res. 2005;13(5):917-927.
  15. 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):125-132.
  16. Pew Internet and American Life Project. Demographics of Internet users; 2011. http://pewinternet.org/Static-Pages/Trend-Data/Whos-Online.aspx. Accessed July 28, 2011.
  17. Gold BC, Burke S, Pintauro S, et al. Weight loss on the web: a pilot study comparing a structured behavioral intervention to a commercial program. Obesity 2007;15(1):155-164.
  18. Krukowski RA, Tilford JM, Harvey-Berino J, S West D. Comparing behavioral weight loss modalities: incremental cost-effectiveness of an internet-based versus an in-person condition. Obesity. 2011;19(8):1629-35.
  19. Krukowski RA, Harvey-Berino J, Ashikaga T, et al. Internet-based weight control: the relationship between web features and weight loss. Telemed J E Health. 2008;14(8):775-82
  20. Funk KL, Stevens VJ, Appel LJ, et al. Associations of internet website use with weight change in a long-term weight loss maintenance program. J Med Internet Res. 2010;12(3):e29.
  21. Micco N, Gold BC, Buzzell P, et al. Minimal in-person support as an adjunct to internet obesity treatment. Ann Behav Med. 2007;33(1):49-56.
  22. Burke L, Conroy M, Serieka S, et al. The effect of electronic self-monitoring on weight loss and dietary intake: a randomized behavioral weight loss trial. Obesity. 2011;19:338-344.
  23. Ueki K, Sakurai N, Tochikubo O. Weight loss and blood pressure reduction in obese subjects in response to nutritional guidance using information technology. Clin Exp Hypertens. 2009;31(3):231-240.
  24. Whitlock EP, Orleans CT, Pender N, Allan J. Evaluating primary care behavioral counseling interventions: an evidence-based approach. Am J Prev Med. 2002;22(4):267-284.

-- The opinions expressed in this commentary are not necessarily those of the editors or of the American Heart Association

AHA Scientific Journals

AHA Scientific Journals