Obesity In Primary Care Setting Research Articles

Steady progress in the behavioral management of obesity in primary-care settings - but innovation needed.

Steady progress in the behavioral management of obesity in primary-care settings - but innovation needed.

The Most Undertreated Chronic Disease: Addressing Obesity in Primary Care Settings.

Purpose of ReviewWhile obesity-related comorbidities are frequently addressed and treated in primary care (PC), obesity itself is undertreated. We review the current treatments for obesity and provide potential provider and system-level strategies for integrating weight management and improving longer term obesity care within PC settings.Recent FindingsWe now understand that the body develops multiple mechanisms to resist weight loss and promote weight regain, making both weight loss and weight loss maintenance challenging. Therefore, weight management often requires medically supervised interventions and should be treated on a long-term basis. However, there are multiple barriers to improving obesity care within PC settings.SummaryClinically, utilizing strategies such as a shared decision-making approach and the 5As to discuss treatment options can facilitate formulating an obesity treatment plan. Utilizing telehealth, a team-based approach, and community partnering can increase patient access to intensive behavioral interventions. Future studies should evaluate other cost-effective methods to implement obesity care into the PC setting.

Weight Can't Wait: A Guide to Discussing Obesity and Organizing Treatment in the Primary Care Setting.

The objective of this study was to develop a simple and practical guide for discussing and managing obesity in primary care settings. This study convened representatives from 12 primary care and obesity specialty organizations for a series of roundtable meetings to discuss the key components of obesity treatment in primary care. Attendees identified the need for a guide for primary care providers that outlined the key steps for discussing obesity with patients and managing their care while recognizing the significant time constraints on such provider/patient encounters. Prevailing themes from the roundtable sessions suggested that the key components of addressing obesity in primary care settings are obtaining patient permission, addressing weight bias, providing a diagnosis, and emphasizing shared decision-making. A modified "6A" framework with the steps "Ask," "Assess," "Advise," "Agree," "Assist," and "Arrange" was deemed appropriate to organize the process of weight management in primary care. An algorithm was developed to provide a script for the patient/provider encounter. The expert panel developed a short, accessible, practical, and informative guide for obesity management by primary care clinicians. Efforts are under way to disseminate the guide to primary care providers through the 11 participating organizations that have endorsed it.

The Joys and Challenges of Delivering Obesity Care: a Qualitative Study of US Primary Care Practices.

Obesity is of epidemic proportion in the USA but most people with obesity do not receive treatment. To explore the experience of providing obesity management among primary care clinicians and their team members involved with weight loss in primary care practices. The study's focus was on examining the use of the Medicare payment code for intensive behavioral therapy for obesity (IBT), but other obesity management services and payment mechanisms were also studied. We conducted 85 interviews of clinicians (physician, advanced practice clinicians, registered dietitian, or other) practicing in primary care practices. Interviews gathered information about treatment approach to obesity, barriers, and facilitators to providing obesity care including the handling of billing and reimbursement (especially use of the IBT code), personal beliefs about the appropriateness of primary care providing weight loss services, and recommendations for improving weight management in primary care practice. The analysis was conducted using a grounded theory hermeneutic editing approach and the constant comparative method. Seventy-five interviews were included in this analysis. We identified three primary themes: (1) clinicians and staff involved in obesity management in primary care believe that addressing obesity is an essential part of primary care services, (2) because providing obesity care can be challenging, many practices opt out of treatment, and (3) despite the challenges, many clinicians and others find treating obesity feasible, satisfying, and worthwhile. Treating obesity in primary care settings poses several challenges but can also be very satisfying and rewarding. To improve the ability of clinicians and practice members to treat obesity, important changes in payment, education, and work processes are necessary.

Utilization of intensive behavioural treatment for obesity in patients with diabetes.

Obesity is a leading public health concern. The Centers for Medicare and Medicaid Services implemented a healthcare procedure code for intensive behavioural therapy (IBT) in 2012 to facilitate payment for addressing obesity in primary care settings, followed by universal coverage by insurers for all adults. Our objective was to understand utilization of IBT from 2009 to 2017 in patients with a diabetes diagnosis. Leveraging electronic health record data from the PaTH Clinical Data Research Network (CDRN), a partnership of six health systems, utilization of IBT was summarized at a yearly basis. The trend of IBT prevalence was examined for patients with diabetes by gender, race, age (>=65 vs <65) and rurality. A total of 205, 913 patients were included. While utilization of IBT is low (0.24% in 2017), use of IBT increased among patients with commercial insurance and Medicaid (codes S9449 and S9470) in 2011, and among patients with Medicare (code G0447) in 2012. IBT users tended to be less than 65 years of age, female, non-White (Black or Hispanic), and reside in urban areas. Overall, use of IBT in patients with diabetes remains low. Future work is necessary to understand the impact of IBT and, if effective, how to increase use within primary care.

Treating Obesity in Underserved Populations

Treating obesity in primary care settings is difficult in any population, but particularly in underserved populations. In this trial, 18 primary care

Efficacy of a mindful-eating programme to reduce emotional eating in patients suffering from overweight or obesity in primary care settings: a cluster-randomised trial protocol

IntroductionLittle is known about the applicability of mindfulness-based interventions in Spanish adults with overweight/obesity. The objective of the present study protocol is to describe the methods that will be used...

A Protocol to Deliver Intensive Behavioral Therapy (IBT) for Obesity in Primary Care Settings: The MODEL-IBT Program.

The Centers for Medicare and Medicaid Services (CMS) initiated coverage of intensive behavioral therapy (IBT) for obesity in 2011, providing beneficiaries 14 to 15 brief, individual counseling visits in 6 months. CMS offered general recommendations for delivering IBT but did not provide an evidence-based treatment protocol, which was the objective of the present research. This review describes the evidence that CMS considered in developing its IBT benefit. It also examines weight losses produced by the intensive lifestyle intervention in the Diabetes Prevention Program(DPP), as well an adapted version of the DPP delivered (for the first 6 months) on the visit schedule recommended by CMS. This new protocol, which was evaluated in a recent randomized trial, provided 14 visits in the first 24 weeks, with 7 additional monthly visits through week 52. As reported previously, the 50 participants with obesity assigned to the new IBT protocol lost a mean of 5.4% of their initial weight at week 24; 46% of participants lost ≥ 5% of their baseline weight. At 1 year, the mean loss was 6.1%, and 44% of participants lost ≥ 5%. With these generally favorable results, the IBT protocol is being posted online for practitioners and researchers to use.

Primary Care Interventions for Obesity: Review of the Evidence.

This review describes the results of randomized controlled trials that have evaluated the efficacy of behavioral interventions for obesity in primary care settings. Most studies have found that high-intensity behavioral counseling (providing 12 or more sessions per year, as defined by the US Preventative Services Task Force), when delivered in-person, by phone, or electronically, produced clinically meaningful weight loss (4 to 7kg). Low- to moderate-intensity behavioral counseling and counseling that did not include behavioral strategies (e.g., motivational interviewing) produced modest losses of 1 to 2kg. The addition of weight loss medication increased mean losses relative to behavioral treatment alone. Consistent with national guidelines, the largest weight losses were achieved with high-intensity counseling, either alone or in combination with obesity pharmacotherapy. Primary care providers can support their patients by inviting them to discuss their weight concerns and referring interested individuals to appropriate interventions.

Obesity in Adolescents and Youth: The Case for and against Bariatric Surgery

Obesity in Adolescents and Youth: The Case for and against Bariatric Surgery

Comprehensive Care for Pediatric Obesity in Primary Care Setting

Comprehensive Care for Pediatric Obesity in Primary Care Setting

Somatic symptom severity among primary care patients who are obese: examining the unique contributions of anxiety sensitivity, discomfort intolerance, and health anxiety.

Prior research indicates the common presentation of somatic symptoms and obesity in primary care settings, as well as links between obesity and somatic symptoms. Anxiety sensitivity, discomfort intolerance, and health anxiety are three variables relevant to somatic symptoms. How those three variables relate to somatic symptom severity among individuals who are obese and the unique variance accounted for by each variable in somatic symptom severity remains unexamined. Among a large sample of primary care patients who are obese (N=342), anxiety sensitivity, discomfort intolerance, and health anxiety collectively accounted for 35% of variance in somatic symptom severity beyond the effects of sociodemographic variables, body mass index, medical morbidity, and depression severity. Health anxiety accounted for the largest amount of unique variance in somatic symptom severity, potentially supporting the relevance of health anxiety to the presentation of increased somatic symptoms among patients who are obese.

Binge Eating among Women Veterans in Primary Care: Comorbidities and Treatment Priorities

BackgroundLittle is known about the clinical profile and treatment priorities of women with binge eating disorder (BED), a diagnosis new to the fifth edition of Diagnostic and Statistical Manual of Mental Disorders. We identified comorbidities and patients' treatment priorities, because these may inform implementation of clinical services. MethodsData were collected from women veteran primary care patients. Analyses compared those who screened positive for BED (BED+), and those without any binge eating symptoms (BED−). ResultsFrequencies of comorbid medical and psychological disorders were high in the BED+ group. The BED+ group's self-identified most common treatment priorities were mood concerns (72.2%), weight loss (66.7%), and body image/food issues (50%). Among those with obesity, a greater proportion of the BED+ group indicated body image/food issues was their top treatment priority (12.9% vs. 2.8%; p < .01), suggesting that these patients may be more apt to seek treatment beyond weight management for their problematic eating patterns. ConclusionsWomen primary care patients with BED demonstrate high medical and psychological complexity; their subjective treatment priorities often match objective needs. These findings may inform the development of targeted BED screening practices for women with obesity in primary care settings, and the eventual adoption of patient-centered BED treatment resources.

Comprehensive Care for Pediatric Obesity in Primary Care Setting

Comprehensive Care for Pediatric Obesity in Primary Care Setting

Biopsychosocial Correlates of Binge Eating Disorder in Caucasian and African American Women with Obesity in Primary Care Settings.

This study examined racial differences in eating-disorder psychopathology, eating/weight-related histories, and biopsychosocial correlates in women (n = 53 Caucasian and n = 56 African American) with comorbid binge eating disorder (BED) and obesity seeking treatment in primary care settings. Caucasians reported significantly earlier onset of binge eating, dieting, and overweight, and greater number of times dieting than African American. The rate of metabolic syndrome did not differ by race. Caucasians had significantly elevated triglycerides whereas African Americans showed poorer glycaemic control (higher glycated haemoglobin A1c [HbA1c]), and significantly higher diastolic blood pressure. There were no significant racial differences in features of eating disorders, depressive symptoms, or mental and physical health functioning. The clinical presentation of eating-disorder psychopathology and associated psychosocial functioning differed little by race among obese women with BED seeking treatment in primary care settings. Clinicians should assess for and institute appropriate interventions for comorbid BED and obesity in both African American and Caucasian patients.

An Educational Program Based on Self-Determination Theory to Address Childhood Obesity in Primary Care Settings

To test a nutrition education program implemented in primary care settings based on the self-determination theory (SDT) with motivational interviewing counseling techniques. Design was a pre- post- assessment, treatment/wait-listed control for 9-11 year old overweight/obese children and their parents (n=31 family pairs). The intervention was six-biweekly, hour-long individual sessions for family pairs over a 12-week period. Telephone calls were made on non-session weeks providing encouragement and problem-solving assistance. Parents participated in three, 90-minute group sessions. Child pre- post- measurements included anthropometrics (weight, height, waist circumference); blood pressure; Block Food and Physical Activity Screener; self-esteem; body image and the SDT constructs - motivation, autonomy, competence, relatedness. Adults received companion surveys for comparisons. Participants provided information on researcher’s support of autonomy. SPSS analysis included one-way ANOVA and paired t-tests. Treatment children (mean age=10.3±0.8 years) decreased from pre to post body mass index (BMI) percentile (P=0.015) and waist circumference (P=0.001); increased self-esteem (P=0.048) and autonomous motivation (P=0.048). Positive trends were reported in dietary intake and physical activity. Treatment parents reported increase in autonomous motivation (P=0.030); perceived competence (P=0.001); relatedness (P=0.025); self-esteem (P=0.031); and decreased controlled motivation (P=0.023). Children and parents reported feeling their autonomy was supported by the researcher. Wait-listed control children increased weight (P=0.001); BMI percentile (P=0.001) and waist circumference (P=0.004); and decreased body dissatisfaction (P=0.047). Positive outcomes were seen when using an SDT-based nutrition education program to support development of autonomy, motivation, competence, and relatedness. This family-centered intervention to address childhood obesity was successful in primary care settings.

Implementation of childhood obesity identification and prevention strategies in primary care: A quality improvement project.

The high incidence and prevalence of childhood obesity, coupled with significant morbidity and financial burden, clearly suggest the need for identification and implementation of effective pediatric obesity prevention strategies in primary care. A solution to this problem includes evidence based clinical guidelines that provide concise, culturally appropriate information on the identification and prevention of childhood obesity in primary care settings. The objective of this quality improvement project was to implement childhood obesity identification and prevention guidelines from evidence-based recommendations into practice. Guidelines were implemented during preventative care visits through the use of a tracking form. The development of the tracking form included input from practice staff resulting in increased fidelity. The tracking form included directions for clear and concise guideline implementation and provided opportunities to record patient BMI, nutritional intake, physical activity, familial obesity prevention education and motivational interviewing and facilitated a practice increase in childhood obesity identification and education. Presence of chart indicators, including nutrition and exercise history, were analyzed to determine the fidelity of the practice change in obesity identification and prevention education. Key outcomes included a significant (p < .0001) practice increase in childhood obesity identification as well as a significant increase (p < .05) in documentation of obesity prevention education through motivational interviewing. Practice change incorporating childhood obesity identification and familial prevention guidelines had positive effects in a pediatric population. Implementation of evidence-based guidelines can result in increased identification of children at risk for childhood obesity and enhanced familial obesity prevention education; leading to the long-term goal of creating healthier lifestyles and decreasing risk factors in a vulnerable population.

Adoption of body mass index guidelines for screening and counseling in pediatric practice.

The purpose of this study was to examine pediatrician implementation of BMI and provider interventions for childhood overweight prevention and treatment. Data were obtained from the American Academy of Pediatrics (AAP) Periodic Survey of Fellows No. 65, a nationally representative survey of AAP members. Surveys that addressed the provision of screening and management of childhood overweight and obesity in primary care settings were mailed to 1622 nonretired US AAP members in 2006. One thousand five (62%) surveys were returned; 677 primary care clinicians in active practice were eligible for the survey. Nearly all respondents (99%) reported measuring height and weight at well visits, and 97% visually assess children for overweight at most or every well-child visit. Half of the respondents (52%) assess BMI percentile for children older than 2 years. Most pediatricians reported that they do not have time to counsel on overweight and obesity, that counseling has poor results, and that having simple diet and exercise recommendations would be helpful in their practice. Pediatricians in large practices and those who had attended continuing medical education on obesity were more familiar with national expert guidelines, were more likely to use BMI percentile, and had higher self-efficacy in practices related to childhood and adolescent overweight and obesity. Multivariate analysis revealed that pediatricians with better access to community and adjunct resources were more likely to use BMI percentile. BMI-percentile screening in primary pediatric practice is underused. Most pediatricians believe that they can and should try to prevent overweight and obesity, yet few believe there are good treatments once a child is obese. Training, time, and resource limitations affect BMI-percentile use. Awareness of national guidelines may improve rates of BMI-percentile use and recognition of opportunities to prevent childhood and adolescent obesity.

Nonsurgical Weight Loss for Extreme Obesity in Primary Care Settings

Effective primary care practice (PCP) treatments are needed for extreme obesity. The Louisiana Obese Subjects Study (LOSS) tested whether, with brief training, PCPs could effectively implement weight loss for individuals with a body mass index (BMI) (calculated as weight in kilograms divided by height in meters squared) of 40 to 60. The LOSS, a 2-year (July 5, 2005, through January 30, 2008) randomized, controlled, "pragmatic clinical trial" trained 7 PCPs and 1 research clinic in obesity management. Primary outcome measure was year-2 percentage change from baseline weight. Volunteers (597) were screened and randomized to intensive medical intervention (IMI) (n = 200) or usual care condition (UCC) (n = 190). The UCC group had instruction in an Internet weight management program. The IMI group recommendations included a 900-kcal liquid diet for 12 weeks or less, group behavioral counseling, structured diet, and choice of pharmacotherapy (sibutramine hydrochloride, orlistat, or diethylpropion hydrochloride) during months 3 to 7 and continued use of medications and maintenance strategies for months 8 to 24. The mean age of participants was 47 years; 83% were women, and 75% were white. Retention rates were 51% for the IMI group and 46% for the UCC group (P = .30). After 2 years, the results were as follows: (1) among 390 randomized participants, 31% in the IMI group achieved a 5% or more weight loss and 7% achieved a 20% weight loss or more, compared with 9% and 1% of those in the UCC group. (2) The mean +/- SEM baseline observation carried forward analysis showed a weight loss of -4.9% +/- 0.8% in IMI and -0.2 +/- 0.3% in UCC. (3) Last observation carried forward analysis showed a weight loss of -8.3% +/- 0.79% for IMI, whereas UCC was -0.0% +/- 0.4%. (4) A total of 101 IMI completers lost -9.7% +/- 1.3% (-12.7 +/- 1.7 kg), whereas 89 UCC completers lost -0.4% +/- 0.7% (-0.5 +/- 0.9 kg); (P < .001 for all group differences). Many metabolic parameters improved. Primary care practices can initiate effective medical management for extreme obesity; future efforts must target improving retention and weight loss maintenance. clinicaltrials.gov Identifier: NCT00115063.

Small Steps to Health: Building Sustainable Partnerships in Pediatric Obesity Care

Given the prevalence of childhood obesity and the limited support for preventing and managing obesity in primary care settings, the Seattle Children's Hospital's Children's Obesity Action Team has partnered with Steps to Health King County to develop a pediatric obesity quality-improvement project. Primary care clinics joined year-long quality-improvement collaboratives to integrate obesity prevention and management into the clinic setting by using the chronic-disease model. Sustainability was enhanced through integration at multiple levels by emphasizing small, consistent behavior changes and self-regulation of eating/feeding practices with children, teenagers, and families; building local community partnerships; and encouraging broader advocacy and policy change. Cultural competency and attention to disparities were integrated into quality-improvement efforts. . Participating clinics were able to increase BMI measurement and weight classification; integrate management of overweight/obese children and family and self-management support; and grow community collaborations. Over the course of 4 years, this project grew from a local effort involving 3 clinics to a statewide program recently adopted by the Washington State Department of Health. This model can be used by other states/regions to develop pediatric obesity quality-improvement programs to support the assessment, prevention, and management of childhood obesity. Furthermore, these health care efforts can be integrated into broader community-wide childhood-obesity action plans.