Can Primary Care Physician–Driven Community Programs Address the Obesity Epidemic Among High-Risk Populations?

Abstract

The high prevalence of obesity in the United States threatens to reverse the trend of decades of health improvement. If we are going to stemthe tideof theobesity epidemic,weneedanswers to several key questions: How can we most effectively drawonthe2mainstrategiesused indiseaseprevention,aclinical strategy targeting those at high riskandabroadenvironmental strategy that targets entire communities?What should be the goal of interventions for thosewhoarealreadyoverweightorobese—achievingclinically significantweight lossoravoidingadditionalweightgain? We will also need to consider how to best serve our diverse population. Sadly, some communities face a disproportionate burdenofobesity.Obesity isparticularly commonamongsome racial and ethnicminority populations, including 59%of AfricanAmericanwomen.1Can interventionsbedevelopedthatare acceptable, accessible, affordable, and effective in the socioeconomicallydisadvantagedpopulationsathighest risk forobesity and consequent health problems? We have known for decades that successful health behavior interventions—for example, the Diabetes Prevention Program trial2—use behavioral principles to improve diet and physical activity. However, intensive lifestyle interventions require substantial resources, including trained interventionists and time commitments from both clinicians and participants. The studybyBennett et al3 in this issueof the journal took a different approach in testing an intervention programwith a modest goal—preventing weight gain for 12 to 18 months— that ismore likely to be feasible in clinical practice. The Shape intervention tested in the study promoted small changes that could prevent the weight gain typically seen in premenopausalAfricanAmericanwomen. Itwasculturallysensitiveand “designed to improve [theparticipants’] overallwell-beingand tomaintain their current body shape.”3 The interventionwas delivered towomenwhowereprimary care patients in a community health center setting. More important, although participants were recruited from primary care, the intervention occurred largely in the community, using participant selfmonitoring via interactive voice response, monthly telephone calls with a registered dietitian, and a 12-month YMCA membership. Weight differences between the randomized groups at 12 and 18 months were statistically significant but small, about 2% of body weight.3 The intervention did not have an effect on cardiovascular disease risk factors, but the study did not have adequate power to detect those outcomes. These results provide somemuch-needed evidence to informdiscussions about preventingweight gain in populations athighrisk for thehealthconsequencesofobesity.Althoughthe studyparticipantswererelativelyyoung(aged25-44years), they hadconsiderable comorbidity: 6%haddiabetesmellitus,more than30%metcriteria formetabolicsyndrome,morethanathird had hypertension, and more than 20% had clinically significant depressive symptoms.3 Moreover, 29% were not employed and 35%had an educational level of high school. Thus, resultsdemonstrate thatamoderate-intensity interventioncan prevent weight gain among a high-risk population. It is unclear which particular elements of the intervention resulted in significantweight differences between the intervention and usual-care groups, but notably, the Shape interventionusedateam-basedapproach involvingdietitiansand coaches and connected participants to community resources through theYMCAmembership. It is oftenhard to resist anenvironment that is conducive to sedentary living and unhealthy eating, so patients need resources they canusewhere they live, learn, work, and play. Because of its outreach beyond the clinical setting, the Shape intervention is an example of linking the clinical approach for high-risk patients with the public-health community approach. The promising results from this study3 and others testing approachesbased inhealthcare settings (eg, thePOWER[Practice Based Opportunities for Weight Reduction] trials4) suggest that these approaches may be effective for preventing weight gain or promotingweight loss, but additional research isneededtodeterminetheextent towhichtheyreduceobesityrelated health risks. More intensive behavioral interventions forweight loss have shown improvements in risk factors such as blood pressure, cholesterol level, and diabetes incidence withbodyweight reductions in the rangeof 5%to 10%.2 Itmay be that greater weight losses than those reported by Bennett et al3 are required to achieve improvements in cardiovascular disease risk factors, and weight maintenancemay need to be sustained longer to achieve such health benefits. Although clinical interventions are important to prevent weight gain in adults and reduce weight in obese adults, we also need effective strategies throughout the lifespan to prevent obesity and its comorbid conditions, as seen at baseline byBennett et al.3 Clinical approaches targeted tohigh-risk patients and public health approaches aimed at reducing risk in the population are important. We can envision a time when such interventions for preventing weight gain as well as successful interventions for weight loss are providedunder the leadership of primary care physicians, while the broader community receives an intervention programof education and environmental change, including effective strategies in worksites, schools, and community organizations. Combining clinical and community approaches may offer the best hope for helping our nation’s citizens achieve andmaintain a healthy weight. Related article page 1770 Research Original Investigation Weight Gain Prevention in BlackWomen