Obesity In Primary Care Research Articles

Liraglutide 3.0 mg and Intensive Behavioral Therapy (IBT) for Obesity in Primary Care: The SCALE IBT Randomized Controlled Trial.

ObjectivePrevious studies have shown additive weight loss when intensive behavioral therapy (IBT) was combined with weight‐loss medication. The present multisite study provides the first evaluation, in primary care, of the effect of the Centers for Medicare and Medicaid Services–based IBT benefit, delivered alone (with placebo) or in combination with liraglutide 3.0 mg.MethodsThe Satiety and Clinical Adiposity—Liraglutide Evidence in individuals with and without diabetes (SCALE) IBT was a 56‐week, randomized, double‐blind, placebo‐controlled, multicenter trial in individuals with obesity who received liraglutide 3.0 mg (n = 142) or placebo (n = 140) as an adjunct to IBT.ResultsAt week 56, mean weight loss with liraglutide 3.0 mg plus IBT was 7.5% and 4.0% with placebo combined with IBT (estimated treatment difference [95% CI]–3.4% [–5.3% to –1.6%], P = 0.0003). Significantly more individuals on liraglutide 3.0 mg than placebo achieved ≥ 5% weight loss (61.5% vs. 38.8%; odds ratio [OR] 2.5% [1.5% to 4.1%], P = 0.0003), > 10% weight loss (30.5% vs. 19.8%; OR 1.8% [1.0% to 3.1%], P = 0.0469), and > 15% weight loss (18.1% vs. 8.9%; OR 2.3% [1.1% to 4.7%], P = 0.0311). Liraglutide 3.0 mg in combination with IBT was well tolerated, with no new safety signals identified.ConclusionsIn a primary care setting, Centers for Medicare and Medicaid Services–based IBT produced clinically meaningful weight loss at 56 weeks, enhanced by the addition of liraglutide 3.0 mg.

A Systematic Review Protocol of the Barriers to Both Physical Activity and Obesity Counselling in the Secondary Care Setting as Reported by Healthcare Providers.

Physical activity and obesity counselling have both been gaining increasing interest in preventive health and treatment. However, most healthcare professionals do not provide advice on these topics nearly as often as they should. There are many reasons for this. Common barriers for the provision of brief advice on physical activity and obesity in both primary and secondary care are lack of time, motivation and knowledge. Systematic reviews have been published on the barriers of physical activity and obesity counselling in the primary care setting, but there is no published work on the barriers present in secondary care. This systematic review aims to assess all published data that discuss the barriers of physical activity and obesity counselling as noted by healthcare providers in secondary care. Four databases will be searched using the same search strategy, and the findings will be compiled using the COM-B model to explore the frequency of a reported barrier. This systematic review will be beneficial not only to practicing healthcare providers, but also the educational and managerial staff of secondary care facilities, as it may highlight the need for further training to fill gaps in the provision of preventive healthcare.

What works and why in the identification and referral of adults with comorbid obesity in primary care: A realist review.

SummaryPrimary care practitioners (PCPs) are well placed to identify individuals with obesity and weight‐related comorbidities and to refer them to weight management services (WMS), but this does not often happen in practice. In this realist review, we searched six databases for intervention studies targeted at PCPs to improve the identification and referral of adults with comorbid obesity. Realist analysis was used to identify context‐mechanism‐outcome (CMO) configurations across 30 included papers (reporting on 27 studies). Most studies used multiple intervention strategies, categorised into: (a) training, (b) tools to improve identification, (c) tools to improve ease of referral, (d) audit/feedback, (e) working in networks/quality circles, and (f) other. The realist synthesis identified 12 mechanisms through which interventions work to improve identification and referral, including increasing knowledge about obesity and awareness of and confidence in WMS among practitioners, improved communication and trust between practitioners and WMS, and higher priority given to weight management among primary care teams. The theory of “candidacy” (a person's eligibility for medical attention and intervention) provided a robust explanatory framework but required refinement: (a) to take account of the different services (primary care and weight management) that patients must navigate to access support; and (b) to acknowledge the importance of wider contextual factors.

Feasibility, acceptability, and effectiveness of a multidisciplinary intervention in childhood obesity from primary care: Nutrition, physical activity, emotional regulation, and family

Childhood obesity is a growing problem with a complex aetiology, for which multidisciplinary interventions are required. Our programme describes a novel structured psychosocial family-based intervention targeting the emotional regulation in childhood obesity, using a train trip metaphor aimed at improving healthy lifestyles for the family. The aims were (a) to describe the feasibility and acceptability of this psychosocial family-based intervention among children with overweight or obesity in primary care and (b) to examine the effectiveness of the "ENTREN-F" programme (with family intervention) compared with the "ENTREN" programme (without family intervention) among Spanish children regarding anthropometric variables, physical activity, emotional well-being, and family functioning. Children were randomly allocated to either ENTREN-F programme (n = 30) or psychological intervention for children (ENTREN, n = 40), and assessments were carried out over time (T0 baseline vs. T1 post/6-month vs. T2 6-month follow-up). Both parent groups expressed high levels of satisfaction with the interventions. ENTREN-F resulted in higher adherence to treatment and was more effective in improving z-body mass index, reducing children's anxiety, and increasing family adaptability than the ENTREN programme. There were no significant changes in parents' emotional well-being and expressed emotion. Both groups improved in the children's emotional well-being and light physical activity. In summary, this multidisciplinary psychosocial family-based intervention was succesful.

Sleep pattern, obesity and healthcare expenditures in Brazilian adults.

The aim of this study was to analyze the relationship between sleep pattern and healthcare expenditures in adults, as well as to identify whether physical activity, biochemical markers and obesity affect this relationship. The sample was composed of 168 adults aged ≥ 50 years attended by two Basic Healthcare Units in Presidente Prudente, SP, Brazil. Health expenditure, sleep pattern, anthropometry, adiposity index, physical activity, metabolic and cardiovascular variables were assessed. Statistical analyses were performed using Kruskal-Wallis, Mann-Whitney and Spearman tests. Sleep disorders were positively correlated to higher costs with medicines and negatively correlated to costs with laboratory tests, even after adjusts by confounders. In addition, healthcare costs were also correlated to physical activity score, blood pressure, obesity and metabolic variables. Severe sleep disorders and high percentage of body fat were associated with increased use of medications. Sleep pattern is correlated to primary care healthcare costs, obesity and physical activity level.

The Low Prevalence of Overweight and Obesity in Czech Breastfed Infants and Young Children: An Anthropological Survey.

The aim of this study is to evaluate the prevalence of overweight and obesity in a sample of children who were exclusively or predominantly breastfed for at least 6 months compared to Czech references that were constructed based on a representative sample of children, regardless of their mode of feeding. Between 2008 and 2011, a longitudinal study on the growth of breastfed infants was carried out in the Czech Republic. Forty-three GP pediatricians addressed parents at 18-month preventive examinations and collected data on the families’ socio-economic conditions and the infants’ feeding conditions. The children were measured (length, weight, and head circumference), and anthropometric measurements from 10 previous preventive examinations were obtained from the health records. Out of the collected 1775 questionnaires, 960 children were selected according to the criteria of the WHO Multicentre Growth Reference Study. For the purpose of this study, 799 children who were exclusively or predominantly breastfed for at least 6 months were selected. We found that the proportions of children who were classified as overweight (>90th percentile) or obese (>97th percentile) at 6, 12, and 18-month examinations were far below the proportions of the Czech references. An update of the Czech references and growth charts is highly recommended by GP pediatricians for the valid assessment of growth and nutritional status, including a screening of overweight and obesity in primary preventive health care.

Motivational Intervention of Obesity in Primary Care Through Physical Activity Program

Summary: Obesity and overweight are significant public health problems, worldwide. Hence, there is the importance of developing and applying strategies that reduce weight in this population. We set out to evaluate the effectiveness of obesity intervention with three different approaches—one of them with a platform that promotes physical activity. Methods: Randomized, controlled, parallel clinical trial that compared three arms, multicenter study in overweight or obese patients, with a 12-month follow-up. The patients were randomized into three groups: Intervention in the primary care center with intervention G1: Control group, which received the usual recommendations of losing weight following the SEEDO 2000 (Sociedad Espanola para el Estudio de la Obesidad) Consensus, G2: Motivational intervention of obesity (IMOAP) with a trained nurse and small periodic work groups, and G3: IMOAP adding the use of a digital platform to record physical activity, monitors it, and, in turn, favors the practice of this (aka iwopi: the concept that physical activity has a positive impact beyond the activity). Variables collected included: weight, height, body mass index (BMI), waist circumference, lipid parameters, blood pressure, and glycosylated hemoglobin. After the interventions, clinical relevance indicators were studied. Relative risk (RR), absolute risk reduction (ARR), relative risk reduction (RRR), and number needed to treat (NNT), both for intention to treat and for biological efficacy. Results: Cholesterol levels in three groups were reduced. The BMI showed a general average reduction. Total cholesterol levels were reduced in all groups, with the largest decrease in G3. Triglyceride levels were significantly reduced in two groups. Glycosylated hemoglobin showed a slight decrease that did not reach a statistically significant value. Conclusions: The digital health platform that stimulates physical activity added to an interventionist motivation in patients with overweight or obesity is a significant additional benefit in terms of weight loss results, BMI reduction, and lipid profile in patients affected by overweight or obesity, and a most effective cost.

Barriers to accessing weight-loss interventions for patients with class II or III obesity in primary care: a qualitative study.

Over 1 million Canadians have class II or III obesity; however, access to weight-loss interventions for these patients remains limited. The purpose of our study was to identify the barriers to accessing medical and surgical weight-loss interventions from the perspectives of 3 groups: family physicians, patients who were referred for weight-loss intervention and patients who were not referred for weight-loss intervention. Between November 2017 and May 2018, we conducted a qualitative exploratory research study using focus groups with family physicians and interviews with patients with class II or III obesity from 1 region in southern Ontario. We conducted a thematic analysis to identify emergent themes and used the barriers to change theory to classify the similarities and differences between the perspectives of family physicians, referred patients and nonreferred patients in first- and second-order barriers. Seventeen family physicians participated in 7 focus groups (1-4 participants/group), and we interviewed 8 referred patients and 7 nonreferred patients. We identified lack of resource supports, logistics and lack of knowledge about weight-loss interventions as first-order barriers to change, and lack of knowledge about root causes of obesity, lack of patient readiness for change and family physicians' perceptions about surgical weight loss as second-order barriers to change. Family physicians and patients had similar perceptions regarding lack of resource supports in the community, logistical issues, family physicians' lack of knowledge regarding weight-loss interventions, patients' lack of motivation and family physicians' perceptions of bariatric surgery as being high risk. They differed regarding the root cause of obesity, with family physicians attributing obesity to multiple extrinsic and intrinsic causes, whereas patients believed obesity was largely due to intrinsic causes alone. It is important to address first- and second-order barriers to accessing weight-loss interventions through continuing professional development activities for family physicians to help ensure effective and timely treatment for patients with class II or III obesity and related comorbidities.

Foundational knowledge regarding childhood obesity: a cross-sectional study of medical students

BackgroundDocumentation and diagnosis of childhood obesity in primary care is poor and providers are often unfamiliar with guidelines. This lack of knowledge may be attributed to insufficient training in medical school and residency; however, no studies have evaluated medical students’ knowledge of recommendations.MethodsWe distributed a modified version of the Physician Survey of Practice on Diet, Physical Activity, and Weight Control to medical students at a single university. Descriptive analyses assessed knowledge and attitudes of childhood obesity and diabetes.ResultsOf the 213 participating students, 74% indicated being unfamiliar with obesity screening recommendations. Few correctly identified BMI percentile cut-points for child overweight (21.2%), obesity (23.7%), and normal weight (29.4%). They reported screening glucose 4.5 years earlier in patients with risk factors compared to those without (p < 0.001).ConclusionsAlthough students recognized the need for earlier diabetes screening in children with risk factors, we determined that overall, student knowledge of obesity-related preventative care was inadequate.

2019 Canadian Surgery Forum Abstracts.

# 01. The future of general surgery training: a Canadian resident nationwide Delphi consensus statement {#article-title-2} Various pedagogical models have been introduced in an attempt to improve and restructure surgical training, but significant obstacles remain. Before implementing national

Management of overweight and obesity in primary care-A systematic overview of international evidence-based guidelines.

SummaryOverweight and obesity are increasing worldwide. In general practice, different approaches exist to treat people with weight problems. To provide the foundation for the development of a structured clinical pathway for overweight and obesity management in primary care, we performed a systematic overview of international evidence‐based guidelines. We searched in PubMed and major guideline databases for all guidelines published in World Health Organization (WHO) “Stratum A” nations that dealt with adults with overweight or obesity. Nineteen guidelines including 711 relevant recommendations were identified. Most of them concluded that a multidisciplinary team should treat overweight and obesity as a chronic disease. Body mass index (BMI) should be used as a routine measure for diagnosis, and weight‐related complications should be taken into account. A multifactorial, comprehensive lifestyle programme that includes reduced calorie intake, increased physical activity, and measures to support behavioural change for at least 6 to 12 months is recommended. After weight reduction, long‐term measures for weight maintenance are necessary. Bariatric surgery can be offered to people with a BMI greater than or equal to 35 kg/m2 when all non‐surgical interventions have failed. In conclusion, there was considerable agreement in international, evidence‐based guidelines on how multidisciplinary management of overweight and obesity in primary care should be performed.

A Group-based Treatment of Overweight and Obesity in Primary Care

A Group-based Treatment of Overweight and Obesity in Primary Care

Use of mobile applications in the management of overweight and obesity in primary and secondary care.

SummaryMobile technology has emerged as a potentially useful application in the process of facilitating weight loss management. While several empirical studies have demonstrated the positive effects of mobile-based interventions, the extent of such effectiveness is still a topic of debate. Thus, the current systematic review involved searching electronic databases for studies on the use of mobile app-based interventions in the management of overweight and obesity among adults over 18 years of age in a primary and secondary care setting. The results of the review revealed that mobile apps are effective tools for weight loss management and sustaining such loss when compared to standard interventions. However, further research is needed to consider the sustained benefits and the applicability of mobile app-based interventions for large-scale population coverage.

Screening and brief intervention for obesity in primary care: cost-effectiveness analysis in the BWeL trial.

BackgroundThe Brief Intervention for Weight Loss Trial enrolled 1882 consecutively attending primary care patients who were obese and participants were randomised to physicians opportunistically endorsing, offering, and facilitating a referral to a weight loss programme (support) or recommending weight loss (advice). After one year, the support group lost 1.4kg more (95%CI 0.9 to 2.0): 2.4 kg versus 1.0 kg. We use a cohort simulation to predict effects on disease incidence, quality of life, and healthcare costs over 20 years.MethodsRandomly sampling from the trial population, we created a virtual cohort of 20 million adults and assigned baseline morbidity. We applied the weight loss observed in the trial and assumed weight regain over four years. Using epidemiological data, we assigned the incidence of 12 weight-related diseases depending on baseline disease status, age, gender, body mass index. From a healthcare perspective, we calculated the quality adjusted life years (QALYs) accruing and calculated the incremental difference between trial arms in costs expended in delivering the intervention and healthcare costs accruing. We discounted future costs and benefits at 1.5% over 20 years.ResultsCompared with advice, the support intervention reduced the cumulative incidence of weight-related disease by 722/100,000 people, 0.33% of all weight-related disease. The incremental cost of support over advice was £2.01million/100,000. However, the support intervention reduced health service costs by £5.86 million/100,000 leading to a net saving of £3.85 million/100,000. The support intervention produced 992 QALYs/100,000 people relative to advice.ConclusionsA brief intervention in which physicians opportunistically endorse, offer, and facilitate a referral to a behavioural weight management service to patients with a BMI of at least 30kg/m2 reduces healthcare costs and improves health more than advising weight loss.

Brief intervention for obesity in primary care: how does student learning translate to the clinical context?

This article was migrated. The article was marked as recommended. There is an international call for more sustainable approaches to healthcare and for graduating doctors to develop the competencies to address the behavioural, psychological and social determinants of health. Obesity is a global challenge, and the case for preventative health is evident. There is growing evidence to support brief interventions for obesity in primary care. The feasibility and acceptability of teaching within classroom contexts have been demonstrated, however there are known barriers to adopting these approaches with patients. It is unclear how well classroom learning translates to the clinical context. 329 final year medical students from Aristotle University of Thessaloniki attended training that had been developed through action research processes at King's College London and adapted to the local context. Students conducted brief interventions with 3,177 overweight or obese patients across 136 primary healthcare facilities over three rotations. Their reflective learning essays were coded for content and thematically analysed to illuminate their experiences. Emergent themes include students' insights into the drivers behind the obesity epidemic and psychosocial barriers to change; transformative experiences using patient-centred approaches to communication and behaviour change; progression in skills and attitudes to broaching obesity in clinical contexts; and insights into the factors that drive patient engagement. Their experiences indicate that facilitative approaches are acceptable to patients, and result in commitment to change where relevant to the patient's agenda.

Tipping the scales: Provider perspectives on a multi-disciplinary approach to obesity

Obesity is a major multi-faceted, chronic disease that increases the risk of morbidity and mortality of children and adults particularly impacting high-risk populations and those of lower socioeconomic status. Given provider time constraints, models of care to effectively and efficiently address obesity in primary care are key. Although physician recommendations can exert a powerful influence on behavior, providers often feel powerless to adequately address obesity due to the complexity of physical and behavioral health problems. This mini-review focuses on describing the feasibility and evidence for tackling obesity through provider-led multidisciplinary weight management programs.

Costs of Preparing to Implement a Family-Based Intervention to Prevent Pediatric Obesity in Primary Care: a Budget Impact Analysis.

The costs associated with implementing evidence-based programs for pediatric obesity contribute to a lack of widespread adoption. This study examined the costs of preparing to implement the Family Check-Up 4 Health (FCU4Health), a family-centered behavioral program for the prevention of pediatric obesity and excess weight gain in primary care. Budget impact analysis was used to estimate the cost of preparing to implement FCU4Health (i.e., the activities to prepare for, but prior to, offering the service to families). Electronic cost capture methods were used to prospectively track personnel time associated with implementation preparation activities. We also estimated the cost of replicating these preparatory activities to inform future decisions to adopt the program and associated budgetary planning. The total cost of FCU4Health implementation preparation in three clinics and developing delivery materials and infrastructure was $181,768, for an average of $60,589 per clinic. Over two thirds of the total cost were personnel related, the largest of which was associated with the time spent developing automated fidelity coding for monitoring (20%), developing and tailoring clinical materials (16%), and training FCU4Health coordinators (15%). Due to these development costs associated with an initial implementation, that we anticipate would not be repeated in full, we estimated the cost to prepare FCU4Health for implementation in a future initiative will range from $15,195 to $17,912 per clinic. This study is a critical step towards equipping decision-makers with comprehensive short-term information about expected costs that are incurred immediately after choosing to adopt an evidence-based program.

Gender disparities in patient education provided during patient visits with a diagnosis of coronary heart disease.

Background:Cardiovascular disease is the leading cause of death in females in the United States. Prior studies have reported that females receive less patient education and preventive counseling for cardiovascular disease as compared with males. The American Heart Association and others have embarked on several initiatives over the last 20 years to narrow this disparity of care. The primary objective of this study was to determine whether a gender disparity remains in the provision of patient education among patients diagnosed with coronary heart disease, a form of cardiovascular disease. The secondary objective was to determine whether there is an association between the provision of patient education and sociodemographic variables and risk factors.Methods:This was a retrospective, cross-sectional, observational study of adults (⩾18 years) diagnosed with coronary heart disease who participated in National Ambulatory Medical Care Survey between the years 2005 and 2014, inclusive. Chi-square tests of independence were performed to address the primary objective. A multivariable logistic regression model was constructed to assess the association between gender and provision of patient education while adjusting for sociodemographic variables and risk factors of interest.Results:A total raw survey sample size of 17,332 patient visits meeting the study inclusion/exclusion criteria was utilized. Patients were predominately white, male, non-Hispanic, and ⩾75 years of age. Females had 0.86 times the odds of receiving patient education compared with males (95% confidence interval = 0.78–0.95, p = 0.0024). After adjusting for covariates of interest, gender remained statistically significant in the multivariable logistic model. In addition, the variables “other payer” (vs private insurance), tobacco use, primary care physician type, obesity, hyperlipidemia, and hypertension were found to be statistically significantly associated with the provision of patient education (p < 0.05) in the multivariable analysis.Conclusion:In the data analyzed, gender disparities exist, as evidenced by a greater proportion of males receiving patient education than females, among coronary heart disease patients during visits seeking medical care. The acceptability of these findings in terms of overall patient management and treatment goals requires further evaluation.

The Family Check-Up 4 Health (FCU4Health): Applying Implementation Science Frameworks to the Process of Adapting an Evidence-Based Parenting Program for Prevention of Pediatric Obesity and Excess Weight Gain in Primary Care.

Implementation experts have recently argued for a process of “scaling out” evidence-based interventions, programs, and practices (EBPs) to improve reach to new populations and new service delivery systems. A process of planned adaptation is typically required to integrate EBPs into new service delivery systems and address the needs of targeted populations while simultaneously maintaining fidelity to core components. This process-oriented paper describes the application of an implementation science framework and coding system to the adaptation of the Family Check-Up (FCU), for a new clinical target and service delivery system—prevention of obesity and excess weight game in primary care. The original FCU has demonstrated both short- and long-term effects on obesity with underserved families across a wide age range. The advantage of adapting such a program is the existing empirical evidence that the intervention improves the primary mediator of effects on the new target outcome. We offer a guide for determining the levels of evidence to undertake the adaptation of an existing EBP for a new clinical target. In this paper, adaptation included shifting the frame of the intervention from one of risk reduction to health promotion; adding health-specific assessments in the areas of nutrition, physical activity, sleep, and media parenting behaviors; family interaction tasks related to goals for health and health behaviors; and coordinating with community resources for physical health. We discuss the multi-year process of adaptation that began by engaging the FCU developer, community stakeholders, and families, which was then followed by a pilot feasibility study, and continues in an ongoing randomized effectiveness-implementation hybrid trial. The adapted program is called the Family Check-Up 4 Health (FCU4Health). We apply a comprehensive coding system for the adaptation of EBPs to our process and also provide a side-by-side comparison of behavior change techniques for obesity prevention and management used in the original FCU and in the FCU4Health. These provide a rigorous means of classification as well as a common language that can be used when adapting other EBPs for context, content, population, or clinical target. Limitations of such an approach to adaptation and future directions of this work are discussed.

Nutrition care practices of primary care providers for weight management in multidisciplinary primary care settings in Ontario, Canada - a qualitative study

BackgroundDespite the recommended guidelines on addressing diet for the management and prevention of obesity in primary care, the literature highlights that their implementation has been suboptimal. In this paper, we provide an in-depth understanding of current nutrition-related weight management practices of primary care providers (PCPs) working in relatively new multidisciplinary health care settings in Ontario.MethodsThree types of multidisciplinary primary care settings were included (2 Family Health Teams, 3 Community Health Centres and 1 Nurse Practitioner-Led Clinic). Participants (n = 20) included in this study were nurse practitioners (n = 13) and family physicians (n = 7) supporting care for adult patients (18 years or older). In-depth interviews were transcribed, coded and the content was analyzed using an integrated approach.ResultsOur analysis showed that most PCPs used anthropometric measures such as weight for screening patients who would benefit from nutrition counselling with a dietitian. The topic of nutrition was generally brought up either during physical examinations, when patients were diagnosed with a chronic disease, or when blood markers were out of normal range. Participants also mentioned that physical examinations are no longer occurring annually, with most PCPs offering episodic care. All participants reported utilizing dietetic referrals, noting the enablers for providing the referral, which included access to an on-site dietitian. Nonetheless, dietetic referrals were mostly used when patients had an obesity-related co-morbidity. Participants mentioned that healthy eating advice was reinforced during follow-up visits with patients only when there was enough time to do so. Electronic Health Records (EHRs) were utilized to facilitate message reinforcement by PCPs, who perceived EHRs to be helpful for viewing what was discussed in the session with the dietitian.ConclusionsPCPs mostly used objective measures to screen for patients who would benefit from nutrition counselling rather than diet assessment, which undermines the importance of dietary intake and overemphasizes weight. With physical examinations occurring less frequently, there will be additional missed opportunities for addressing nutrition-related concerns. The presence of a dietitian on site allowed for PCPs to refer patients to nutrition counselling. Having sufficient time during medical visits and EHRs seemed to facilitate message reinforcement by PCPs in follow-up visits with patients.