Goutham Rao|Lora E. Burke|Bonnie Spring|Linda J. Ewing|Melanie T. Turk|Alice H. Lichtenstein|Marc Andre Cornier|J. David Spence|Michael James Coons
New and Emerging Weight Management Strategies for Busy Ambulatory Settings
Burke Foundation|Alice-Salomon-Hochschule Berlin|Michael & Associates
homecirculationvol 124 10new emerging weight management strategies busy ambulatory settings free accessresearch articlepdfepubaboutview pdfview epubsections toolsadd favoritesdownload citationstrack citationspermissions shareshare onfacebooktwitterlinked inmendeleyreddit jump tofree accessresearch articlepdfepubnew emerging weight management strategies busy ambulatory settingsa scientific statement american heart association goutham rao lora e burke bonnie j spring linda j ewing melanie turk alice h lichtenstein marcandre cornier j david spence michael coons behalf american heart association obesity committee council nutrition physical activity metabolism council clinical cardiology council cardiovascular nursing council kidney cardiovascular disease stroke council goutham raogoutham rao lora e burkelora e burke bonnie j springbonnie j spring linda j ewinglinda j ewing melanie turkmelanie turk alice h lichtensteinalice h lichtenstein marcandre corniermarcandre cornier j david spencej david spence michael coonsmichael coons behalf american heart association obesity committee council nutrition physical activity metabolism council clinical cardiology council cardiovascular nursing council kidney cardiovascular disease stroke council originally published8 aug 2011httpsdoiorg101161cir0b013e31822b9543circulation 201112411821203other versions articleyou viewing recent version article previous versions january 1 2011 previous version 1 introductionrecent data centers disease control prevention show staggering 68 american adults either overweight obese 34 obese1 although evidence prevalence stabilizing obesity remains extremely serious public health problem major risk factor wide range medical eg type 2 diabetes mellitus social eg discrimination employment education settings psychological eg depression conditions2although effectiveness different obesity treatments evaluated systematically3 rational safe effective treatments majority overweight obese patients benefit remain elusive new medications emerging impact weight loss modest longterm adverse effects uncertain4 bariatric surgery effective expensive appropriate small proportion patients benefits outweigh risks effective safe commercial noncommercial behavior modification programs scarce changes public policy built environment5 may curb obesity changes take long time bring magnitude impact yet established clearly recent review example concluded soft drink taxes small impact populations average body mass index bmi6it widely acknowledged single strategy solve obesity problem effective public health initiatives prevent treat obesity require involvement multiple stakeholders including patients employers health plans governments levels food beverage industries healthcare providers78 among healthcare providers deliver care busy ambulatory settings including primary care physicians nurse practitioners nurses registered dietitians others screening counseling obesity settings widely recommended910 unfortunately ample evidence physicians healthcare professionals poorly equipped tackle problem survey conducted 2006 revealed example 65 obese patients advised lose weight physicians11 lack knowledge skills practical tools identified repeatedly barriers identification management obesity healthcare professionals1214the purpose statement provide overview new emerging tools strategies discussing weight assisting overweight obese patients tools strategies used practically busy ambulatory settings included goal provide clinicians evidencebased strategies tackle problem obesity settings patients seen wide variety problems using strategies course important assess patients overweight obesity critical step addressed another pending american heart association scientific statement assessment adiposity14a basis literature review divided strategies 3 categories 1 appropriate ways discussing body weight patients including readiness change 2 approaches involve multidisciplinary collaboration among healthcare professionals 3 strategies make use information technology deliver weight management programs although many weight management approaches make use technology evaluated busy ambulatory settings believe technological approaches included present statement potential impact large numbers participants relatively easy recommend administer refer settings1 discussing weight patientsoverviewthis section includes review existing evidence 1 acceptable methods raising discussing issue weight 2 practical methods assessing readiness change motivation attaining healthier weight 3 practical strategies assessment eating physical activity behaviors busy settingssearch strategywe searched articles explicitly described strategies discussing weight patients search terms including physicianpatient relations primary care etc communication counseling etc used combination obesity weight loss identify relevant studies following databases pubmed embase cinahl psycinfo cochrane central new york academy medicine grey literature collection searched reports published 2002 november 2010resultswe retrieved 157 unique citations pubmed 59 embase unique citations indentified databases vast majority reports relevant citations reviewed included descriptive studies perspectives practices providers eg perceived barriers weight management primary care patients recall receiving weight management advice reports reviewed described strategies discussing weight considered time consuming impractical busy clinical settings reviewed 23 reports depth table 1table 1 studies included section 1 discussing weight patientsstudydesigndescriptionsampleindependent variablesoutcome measuresresults assessment discussing weight readiness changeblixen et al 200615descriptive survey examine perceptions obesity weightmanagement preference among black white general internal medicine female clinic patientsn480 surveys mailed 240 white 240 black female patients 256 surveys returned 55 response rate blacks whites included study n229 100 female 36 white 54 black 11 age 515141 white 498149 black bmi 37679 kgm2 white 42294 kgm2 black icd9 diagnosis obesityblack white races18item questionnaire developed 5 themes arose focus group data 1 perceptions attitudes weight2 aspects life weight affects3 weight associated medical knowledge4 past weight loss attempts associated factors and5 help losing weight women want pcpcompared white women black women expressed greater need physicians help weight loss strategies following areas oneonone assistance pcp p0001 group meeting pcp dietician women p0007 referral pcp dietician p0031 prescribe medication weight loss p0006 individual counseling pcp p0015 take part weight loss classes pcps practice p0011 pcp review adverse outcomes dangers weight gain p0001 pcp firmly discuss need weight loss p0003bolognesi et al 200616rct examine effect gpadministered physical activity counseling intervention bmi waist circumference physical activity stage changeusualcare control group n55 48 completed pace intervention group n55 48 completed 729 age 4170 531 female 833 married overweight obese patients 8 practices emilia romagna italy physical activity contraindicatedintervention group pace protocol physical activity counseling included baseline assessment stage change followed standard procedure stage required 25 min interaction gp patient 2 3wk followup via mail telephone reinforced stagespecific themes protocol usualcare control group general discussion recommendations healthy lifestyle provided gp 25 minbmi change kgm2 5 6mo followup waist circumference change cm 5 6mo followup stage change physical activity change stage level selfreported intervention group stage readiness physical activity leisure timeancova analyses controlled baseline bmi waist circumference revealed significant difference intervention control groups 5 6mo followup intervention group decreased bmi waist circumference whereas control group increased p001 within intervention group 60 precontemplators moved contemplation preparation followup 514 contemplators preparers baseline moved action maintenance stageboudreaux et al 200317crosssectional descriptive study investigate relationships decisional balance selfefficacy stage change avoiding dietary fat engaging exercise regularlyn515 adult patients 4 public primary care clinics 60 black 81 women 43 married 71 uninsured age 4514 monthly household income 490453exercise selfefficacy 5item 5point likert scale 1not confident 5extremely confident assessing confidence ability exercise various circumstances exercise decisional balance 16item 5point likert scale 1not important 5extremely important assessing degree positive negative feelings derived exercise dietary fat selfefficacy 12item tool assessing confidence avoiding dietary fat 5point likert scale 1not likely 5extremely likely dietary fat decisional balance 8item 5point likert scale 1not important 5extremely important assessing degree positive negative feelings derived reducing dietary fatreadiness exercise classified precontemplation contemplation preparation action maintenance engaging maintaining regular exercise routine weekly basis least 3 exercise sessions 20 min readiness decrease dietary fat classified precontemplation contemplation preparation action maintenance response question consistently avoid eating high fat foods followed 5 yesno questions actual low nofat eating behaviorsstage change avoiding dietary fat significantly related stage change exercise p0001 274 study population stage congruent exercise avoiding dietary fat 373 1 stage apart eg contemplation dietary fat preparation exercise 353 1 stage apart eg precontemplation dietary fat preparation exercise majority sample stage incongruent suggests intervention efforts providers tailored stage change behaviorbrown et al 200618qualitative study using semistructured interviews explore experiences perceptions support among obese primary care patientsn28 adult patients 5 general medicine practices sheffield united kingdom mean age 56 range 1977 mean bmi 356 kgm2 range 294615 kgm2 female 64naexperiences perceptions obese patients related support carethemes emerged level support weight loss disappointment related told need lose weight practical advice support patients expressed dissatisfaction hurried office visits provided limited resources weight loss efforts desired specific support services available practitioners officecounterweight project team 200819prospective assessment comprehensive program manage obesity primary care practices65 general medical practices 7 regions united kingdom agreed participate 56 participated n1906 patients enrolled n1419 12mo followup n825 24mo followup age 494135 bmi 37169 kgm2 female 77intervention registered dieticians trained gps pns screening treatment pathways counterweight program pns delivered patient education intervention based patients stage readiness lose weight contemplation action stages asked participate patients ready change given information health benefits 510 weight loss advised think weight loss patients committed 9 appointments 12 moprimary outcomes weight change 12 24 mo percentage patients losing maintaining 5 12 24 momean 12mo weight change 642 attendees 296 kg 95 ci 347 244 307 attendees maintained 5 weight loss mean 24mo weight change 357 attendees 23 kg 95 ci 32 14 319 attendees maintained 5 weight lossgreenwood et al 200820pilot crosssectional studies develop assess eating behavior clinical screening tool use primary care patientsphase 1 pilot n48 adult patients 2 family medicine clinics utah health research networkage 426121 yfemale 54white 77phase 2 crosssectionaln261 adult patients 2 family medicine clinicsage 384117 yfemale 58white 80education 15734 ybmi 27772 kgm2phase 1 two versions screening questionnaire physical activity eating behaviors consumption restaurant food large portion sizes sugaradded beverages fruits vegetables breakfast phase 2 bmi overweight obese status factors related reported eating behaviors bmi objectively measured using weight kilograms divided height meters squared overweight 245 2945 kgm2 obese 295 kgm2phase 1 participants perceptions questions terms ease understanding response accuracy actual representativeness behavior phase 2 selfreported eating behaviors physical activity 14item final version questionnairephase 1 reporting behaviors previous day said less representative behavior reporting typical behaviors period time final version 14 questions specific eating behaviors including 1d 1wk recall well typical behavior phase 2 additional sugaradded beverage typically consumed day associated 061unit increase bmi p0006 every 1day increase moderate physical activity associated 091unit decrease bmi p0001 odds classified obese 147 higher p0002 unit increase frequency consuming fullsize portion restaurant meal compared never consuming fullsize portion restaurant mealhuang et al 200421crosssectional descriptive study using exit interviews evaluate patients recollection physicians recommendations weight loss effect md weight loss counseling patients understanding motivation toward behaviors weight lossn210 convenience sample adult primary care clinic patients bmi 25 kgm2 english first language mean age 52 range 1882 mean bmi 39 kgm2 range 2665 kgm2 female 74 black 76 insurance status free care selfpay 66analyses adjusted age race sex literacy leveltopics patient interview questions 1 understanding association weight health2 effect 10 weight loss3 specific weight loss advice md4 weight loss motivation5 past current weight loss efforts6 readiness weight loss79 recalled advised lose weight 28 recalled receiving specific recommendations weight loss 5 recalled advised combine dietary exercise strategies weight loss patients recalled counseled lose weight likely contemplation preparation action maintenance stages change weight loss versus precontemplative stage 21924 p0001paxton et al 201022secondary data analysis examine feasibility validity sensitivity change stc brief dietary screening tooln463 age 58492 female 498 white 72 bmi 38465 kgm2analyses controlled baseline age hispanic ethnicity8item stc tool compared nci percent energy fat screener baseline 4 moindividual stc items significantly correlated summary score r039059 p005 stc summary score significantly correlated nci fat screener measurement fat intake r039 p005 stc summary score change significantly correlated decrease fat intake 4 mo r022 p005pollak et al 200723descriptive study weight loss discussed physicians female family practice clinic patients overweight obese using baseline surveys audiotaped patient visits 1mo followup surveysn25 patients age 5911 female 100 white 50 bmi 3711 kgm2 n7 physicians age 4310 female 57 white 57 bmi 223 kgm2mi two coders evaluated mi strategies used mds empathy mi spirit miadherent actions md advice given patient permission affirming supportive statements emphasizing patient control minonadherent actions md advice given without patient permissionpatient selfreported selfefficacy readiness lose weight immediately office visit 1mo followup patient selfreported attempts lose weight altering dietary intake exercise habits 1mo followuppatients likely report changing exercise habits 1 mo mds displayed higher levels empathy r050 p002 patients likely report attempting lose weight 1 mo mds used miadherent techniques r042 p008simkinsilverman et al 200524descriptive study baseline data primary care weight control project regarding prevalence previous mdadministered weight loss advice predictors identification obese patients well predictors weight loss advicen255 adult patients age 484108 female 751 white 833 bmi 34956 kgm2 n18 pcps age 38155 female 61 white 72 bmi 34956 kgm2bmi objectively measured waist circumference level physical activity dietary intake mood readiness weight management dichotomized precontemplationcontemplation preparationactionmaintenance percentage previous office visits pcp medical history patient selfreport sociodemographic variablespatient selfreport previous mdadministered weight loss advice chart review documentation indicating pcp discussed weight physical activity patient obesity diagnosis per chart reviewstage change weight control significant predictor patientreported mdadministered weight loss advice 036 95 ci 015088 chartdocumented mdadministered weight loss advice 037 95 ci 020069 multivariate analysessegalisaacson et al 200425descriptive study validate reaps combination nutrition education firstyear medical students correlating responses block ffqn110 firstyear medical students age 24238 female 44 white 65 bmi 23450 kgm2block 1998 ffqcorrelations scores reaps block ffq vegetable fruit dairy added fat meat servings well estimated nutrient intake fiber sugar total fat cholesterolthe reaps significantly correlated block ffq variables except 1 meat servings p051 2 fiber intake associated highfiber starch whole grain foods p008 3 total fat intake fish poultry meat p068scott et al 200426descriptive studyobesity epidemic united states industrialized countries contributes significantly population morbidity mortality pcps see substantial portion obese population yet rarely counsel patients lose weightweight counseling n39 adults 20 12children 2 20 82female 123white 93no weight counseling n337adults 20 88children 2 20 918female 877white 907frequency weight loss counseling primary care visitsdescriptive field notes outpatient visits collected part multimethod comparative case study used study patterns physicianpatient communication weight control 633 encounters family practices midwestern state68 adults 35 children overweight excess weight mentioned 17 encounters overweight patients whereas weight loss counseling occurred 11 overweight adults 8 overweight children weight loss counseling encounters patients formulated weight problem making reason visit explicitly implicitly asking help weight loss clinicians framing weight medical problem exacerbating factor another medical problemjay et al 200927nonrandomized waitlistcontrol design assess impact obesity counseling curriculum residents 5hour multimodal obesity counseling curriculum based 5 assess advise agree assist arrange using didactics roleplaying standardized patientscontrol group n74 mean age 43501345 yfemale 73black 68bmi 3450461 kgm2 intervention group n78 mean age 46111373 yfemale 71black 78bmi 3383386 kgm2bmi health status number comorbidities patientpatient report physicians use 5 assessed structured interview survey main outcomes whether obese patients counseled diet exercise weight loss rate counseling quality counseling provided percentage 5 skills performed visit univariate statistics tests used compare rate quality counseling 2 resident groups logistic linear regression used isolate impact curriculum controlling patient physician visit characteristicsa large percentage patients seen groups residents received counseling weight diet andor exercise 70 quality counseling low curriculum curriculum groups mean 366 versus 312 19 possible 5 counseling strategies p021 difference significant however controlling patient physician visit characteristics residents curriculum group appeared provide significantly higherquality counseling control group standardized coefficient018 r2 change29 p005carels et al 200528this investigation designed improve bwlp treatment outcomes providing sc individuals experiencing difficulties weight loss treatmentbwlpsc n23 female 852white 929 bwlp n23 female 885white 923weight physical activityfitness dietary intakechanges weight cardiorespiratory fitness selfreported physical activity diet ie calories percentage daily intake fat protein carbohydrates response treatment assessed fiftyfive obese sedentary adults randomly assigned bwlpsc bwlpparticipants significantly decreased weight increased physical activityfitness improved dietary intake p005 bwlpsc mi participants lost weight engaged greater weekly exercise bwlp sc matched participants receive mi p005heintze et al 201029crosssectional studythe aim study assess gps patients practices attitudes overweight encountered preventive counseling talksn51 age 3550 2115160 36575 403 1 patient wno age specification female 17 bmi kgm2 250299 385300349 404350399 13740 58natwelve gps audiotaped preventive counseling talks overweight patients including assessment individual risk profiles medical recommendations fiftytwo dialogues transcribed submitted qualitative content analysisdietary advice increased physical activity discussed often talks recommendations appeared individual patients given chance reflect causes overweight counseling talksburke et al 20103024mo rct behavioral intervention examining effect 3 approaches sm weight loss sm adherencen210 pda n6864 853 women809 whiteage 46792 ybmi 34946 kgm2941 retention 6 mo pda plus daily fb n7065 843 women786 whiteage 46495 ybmi 34846 kgm2929 retention 6 mo paper diary n7263 847 women764 whiteage 47485 ybmi 33445 kgm2875 retention 6 moall subjects received 24mo behavioral weight loss program paper diary use paper diary sm diet exercise pda use pda dietary exercise software pda includes date time stamp measure adherence sm pdafb use pda sm automated message delivered daily tailored diary entries weight loss 6 mointentiontotreat analysis 6mo weight change paper diary 5359pda 5570pdafb 7366 p012 proportion group achieved 5 weight loss compared pdafb 63 paper record 46 p005pda 49 p005 median adherence sm paper record 55pda 80pdafb 90 p001ward et al 200931qualitative study understand obese black patients perceive physicians role treatment obesity identify specific provider behaviors may motivate hinder attempts weight lossn43 women 63 age 3064 median 50 bmi 302577 kgm2naqualitative study involving 8 focus groupsphysicians must cognizant potential unintended consequences techniques use educate counsel black men women obesity particularly may perceived negative act alienate obese patients seeking care needdutton el al 200432crosssectional nonrandom sampling study determine patients prefer physicians communicate topic obesityn143 women 895 white 645 age 468125 bmi 36974 kgm2descriptor terms used describe weightcrosssectional nonrandom sampling study patients seeking treatment weight loss rated desirability 12 terms describe excess weight physicians rated likelihood would use terms clinical encounters participants rated terms 5point scalephysicians generally reported used terminology patients rated favorably tended avoid terms patients may find undesirablewhitlock et al 200233evidencebased approach promote broader appreciation importance behavioral counseling interventions clinical care context deliverynananabehavioral counseling interventions clinical settings important means addressing prevalent healthrelated behaviors lack physical activity poor diet substance tobacco alcohol illicit drug use dependence risky sexual behavior underlie substantial proportion preventable morbidity mortality united statesunrod et al 200734evaluation effectiveness computertailored intervention designed increase smoking cessation counseling pcpsn518 intervention n270 58 women61 whiteage 435147 control n248 64 women63 whiteage 428142 yphysician implementation 5 quit rate length quit attempts number quit attempts stageofchange progressionphysicians patients randomized either intervention control conditions addition brief smoking cessation training intervention physicians patients received 1page report characterized patients smoking habitsthe use brief computertailored report improved physicians implementation 5 modest effect patients smoking behaviors 6 mo interventionquinn et al 200535survey studyn4207 638 women 70 white 311 age 2540 428 age 4154 261 age 55 ydemographics health status outpatient utilizations smoking