Treatment Of Obesity In Primary Care Research Articles

Pragmatic online obesity treatment in primary care: a hybrid randomized clinical trial of implementation strategies

Online behavioral weight loss (BWL) in primary care is effective and disseminable. This trial compared two implementation approaches on program uptake, use, and weight loss via a pragmatic hybrid type 2 implementation-effectiveness design to evaluate online BWL implementation (Rx Weight Loss [RxWL]) and effectiveness. This manuscript presents the implementation results. RxWL was implemented across a state-wide network of primary care clinics using lower- and higher-intensity implementation strategies (Basic [base program] and Enhanced [base plus enhanced training and dashboard], respectively) between 2018 and 2022. Nurse care managers (NCMs; N = 23) were recruited and block-randomized to implementation condition. Adult primary care patients (body mass index [BMI] > 25 kg/m2, internet-connected device access) were referred and enrolled by their NCMs. Outcomes were the proportion of eligible patients who enrolled in and completed RxWL by NCM condition, initial weight loss and regain over 12 and 24 months by NCM condition, and clinician acceptability and feasibility. NCMs (N = 12 Enhanced, N = 11 Basic) in Enhanced enrolled more patients (N = 490) than in Basic (N = 164). Although the proportion of patients who completed RxWL and mean weight loss did not differ by condition, different enrollment rates resulted in the Enhanced condition engaging more patients. NCMs rated RxWL as acceptable and feasible with no difference by condition. Findings support connecting primary care patients with technology-based health behavior change programs. Clinical trial registration number: ClinicalTrials.Gov identifier NCT03488212: https://clinicaltrials.gov/ct2/show/NCT03488212. Trial registration: clinicaltrials.gov Identifier: https://clinicaltrials.gov/study/NCT03488212.

Qualitative inquiry with persons with obesity about weight management in primary care and referrals.

Referrals to evidence-based weight management in the community-commercial sector are aligned with clinical recommendations but underutilized. This qualitative study explored patients' perceptions and expectations about obesity treatment in primary care and referral to community-commercial sector programs. Individual semi-structured interviews were conducted with a sample of US persons with obesity via telephone. Audiotape transcripts, interviewer notes, and independent review of data by two investigators allowed for data and investigator triangulation. Transcripts were analyzed using thematic analysis. Data saturation was reached with 30 participants who had a mean age of 41.6 years (SD 9.4), 37% male, 20% Black/African American and 17% Hispanic, 57% college educated, and 50% were employed full-time. Three primary themes emerged: (1) frustration with weight management in primary care; (2) patients expect providers to be better informed of and offer treatment options; and (3) opportunities and challenges with referrals to community-commercial programs. Patients expect that providers offer personalized treatment options and referrals to effective community-commercial programs are an acceptable option. If patient-level data are shared between clinical and community entities to facilitate referrals, then privacy and security issues need attention. Future research is needed to determine feasibility of implementing clinical to community-commercial referrals for obesity treatment in the United States.

COMPARATIVE ANALYSIS OF EFFECTIVENESS OF OBESITY TREATMENT IN PRIMARY CARE USING PATIENT-ORIENTED APPROACH WITH MOTIVATIONAL COUNSELING FOR LIFESTYLE CORRECTION AND ITS COMBINATION WITH ARMODAFINIL THERAPY IN PATIENTS WITH CONCOMITANT SHIFT WORK SLEEP DISORDER

Aim: Conduct a comparative analysis of effectiveness of obesity treatment in primary care using patient-oriented approach with motivational counseling for lifestyle correction and its combination with armodafinil therapy in patients with concomitant shift work sleep disorder. Materials and Methods: 75 patients with obesity were studied, 38 patients had shift work disorder. Patients were divided into 2 groups: I (37 patients with obesity treated with motivational counseling) and II (38 patients with obesity and shift work disorder treated additionally with armodafinil 150 mg daily). The examination was at baseline, after 1st, 3th and 6th months. Statistical analysis was provided. Results: After 1 month of treatment, there were improvement of eating behavior, level of anxiety and depression, prognosis of diabetes development. At 3rd month, more pronounced changes were observed in 2nd group: 10% body weight loss, changes in eating behavior, sleep quality, anxiety level (p<0.05). After 6 months, examined indicators in both groups normalized, but dynamics in 2nd group was more significant; armodafinil-treated group had significantly better results in body weight loss, BMI, WC, HC, ConI, AVI, BPs, HOMA index, serotonin, leptin, levels of anxiety and depression, eating behavior, daytime dysfunction, level of sleepiness, quality of life and risk of developing diabetes. Conclusions: The use of armofafinil in addition to patientoriented motivational counseling in lifestyle correction (“5 As” and “5R”) in patients with obesity connected with shift work disorder and excessive daytime sleepiness allows to reduce body weight by more than 16,52%, in contrast to isolated use of the same technique of motivational counseling in obese patients without sleep disorder (only 5,51%).

Pragmatic implementation of a fully automated online obesity treatment in primary care.

Behavioral obesity treatment implemented in primary care is efficacious but typically involves face-to-face or phone contact. This study evaluated enrollment, engagement, and 12-week weight loss in a fully automated online behavioral weight-loss intervention implemented pragmatically in a primary care network. As part of routine primary care, providers and nurse care managers offered a no-cost online obesity treatment program to 1,721 patients. Of these, 721 consented and were eligible (aged 18-75 yearswith BMI ≥ 25 kg/m2 and internet access), and 464 started the program. The program included 12 weekly online lessons, a self-monitoring platform, and automated feedback. More than one-quarter of patients who were offered the program (26%) initiated treatment. In intent-to-treat analyses using all data available, mean 12-week weight change was -5.10% (SE=0.21). Patients who submitted their weights on all 12 weeks (37% of 464) lost an estimated 7.2% body weight versus 3.4% in those submitting less frequently. This fully automated online program, implemented into the routine workflow of a primary care setting without any human counseling or researcher involvement, produced clinically meaningful short-term weight loss. Greater program engagement was associated with greater weight loss; efforts are needed to understand barriers to engagement.

Contextual influences on implementation of online behavioral obesity treatment in primary care: formative evaluation guided by the consolidated framework for implementation research.

Online behavioral obesity treatment is a promising first-line approach to weight management in primary care. However, little is known about contextual influences on implementation. Understand qualitative contextual factors that affect the implementation process, as experienced by key primary care stakeholders implementing the program. Online behavioral obesity treatment was implemented across a 60-clinic primary care practice network. Patients were enrolled by nurse care managers (NCMs; N = 14), each serving 2-5 practices. NCMs were randomized to one of two implementation conditions-"Basic" (standard implementation) or "Enhanced" (i.e., with added patient tracking features and more implementation strategies employed). NCMs completed qualitative interviews guided by the Consolidated Framework for Implementation Research (CFIR). Interviews were transcribed and analyzed via directed content analysis. Emergent categories were summarized by implementation condition and assigned a valence according to positive/negative influence. Individuals in the Enhanced condition viewed two aspects of the intervention as more positively influencing than Basic NCMs: Design Quality & Packaging (i.e., online program aesthetics), and Cost (i.e., no-cost program, clinician time savings). In both conditions, strongly facilitating factors included: Compatibility between intervention and clinical context; Intervention Source (from a trusted local university); and Evidence Strength & Quality supporting effectiveness. Findings highlight the importance of considering stakeholders' perspectives on the most valued types of evidence when introducing a new intervention, ensuring the program aligns with organizational priorities, and considering how training resources and feedback on patient progress can improve implementation success for online behavioral obesity treatment in primary care.

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.

Primary care clinicians' perspectives on clinical decision support to enhance outcomes of online obesity treatment in primary care: A qualitative formative evaluation.

Online behavioral treatment for obesity produces clinically-meaningful weight losses among many primary care patients. However, some patients experience poor outcomes (i.e., failure to enroll post-referral, poor weight loss, or premature disengagement). This study sought to understand primary care clinicians' perceived utility of a clinical decision support system (CDSS) that would alert clinicians to patients' risk for poor outcome and guide clinician-delivered rescue interventions to reduce risk. Qualitative formative evaluation was conducted in the context of an ongoing pragmatic clinical trial implementing online obesity treatment in primary care. Interviews were conducted with 14 nurse care managers (NCMs) overseeing patients' online obesity treatment. Interviews inquired about the potential utility of CDSS in primary care, desired alert frequency/format, and priorities for alert types (non-enrollment, poor weight loss, and/or early disengagement). We used matrix analysis to generate common themes across interviews. Nearly all NCMs viewed CDSS as potentially helpful in clinical practice. Alerts for patients at risk for disengagement were of highest priority, though all alert types were generally viewed as desirable. Regarding frequency and delivery mode of patient alerts, NCMs wanted to balance the need for prompt patient intervention with minimizing clinician burden. Concerns about CDSS emerged, including insufficient time to respond promptly and adequately to alerts and the need to involve other support staff for patients requiring ongoing rescue intervention. NCMs view CDSS for online obesity treatment as potentially feasible and clinically useful. For optimal implementation in primary care, CDSS must minimize clinician burden and facilitate collaborative care.

Effects of a 2-Year Primary Care Lifestyle Intervention on Cardiometabolic Risk Factors: A Cluster-Randomized Trial.

Intensive lifestyle interventions (ILIs) are the first-line approach to effectively treat obesity and manage associated cardiometabolic risk factors. Because few people have access to ILIs in academic health centers, primary care must implement similar approaches for a meaningful effect on obesity and cardiometabolic disease prevalence. To date, however, effective lifestyle-based obesity treatment in primary care is limited. We examined the effectiveness of a pragmatic ILI for weight loss delivered in primary care among a racially diverse, low-income population with obesity for improving cardiometabolic risk factors over 24 months. The PROPEL trial (Promoting Successful Weight Loss in Primary Care in Louisiana) randomly allocated 18 clinics equally to usual care or an ILI and subsequently enrolled 803 (351 usual care, 452 ILI) adults (67% Black, 84% female) with obesity from participating clinics. The usual care group continued to receive their normal primary care. The ILI group received a 24-month high-intensity lifestyle-based obesity treatment program, embedded in the clinic setting and delivered by health coaches in weekly sessions initially and monthly sessions in months 7 through 24. As recently demonstrated, participants receiving the PROPEL ILI lost significantly more weight over 24 months than those receiving usual care (mean difference, -4.51% [95% CI, -5.93 to -3.10]; P<0.01). Fasting glucose decreased more in the ILI group compared with the usual care group at 12 months (mean difference, -7.1 mg/dL [95% CI, -12.0 to -2.1]; P<0.01) but not 24 months (mean difference, -0.8 mg/dL [95% CI, -6.2 to 4.6]; P=0.76). Increases in high-density lipoprotein cholesterol were greater in the ILI than in the usual care group at both time points (mean difference at 24 months, 4.6 mg/dL [95% CI, 2.9-6.3]; P<0.01). Total:high-density lipoprotein cholesterol ratio and metabolic syndrome severity (z score) decreased more in the ILI group than in the usual care group at both time points, with significant mean differences of the change of -0.31 (95% CI, -0.47 to -0.14; P<0.01) and -0.21 (95% CI, -0.36 to -0.06; P=0.01) at 24 months, respectively. Changes in total cholesterol, low-density lipoprotein cholesterol, triglycerides, and blood pressure did not differ significantly between groups at any time point. A pragmatic ILI consistent with national guidelines and delivered by trained health coaches in primary care produced clinically relevant improvements in cardiometabolic health in an underserved population over 24 months. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02561221.

Peer-Assisted Lifestyle (PAL) intervention: a protocol of a cluster-randomised controlled trial of a health-coaching intervention delivered by veteran peers to improve obesity treatment in primary care

IntroductionAmong US veterans, more than 78% have a body mass index (BMI) in the overweight (≥25 kg/m2) or obese range (≥30 kg/m2). Clinical guidelines recommend multicomponent lifestyle programmes to promote...

Rationale and design for a pragmatic effectiveness-implementation trial of online behavioral obesity treatment in primary care

BackgroundCurrent guidelines recommend behavioral intervention to achieve a modest weight loss (e.g., 3–5%) as a first-line obesity treatment. Online behavioral obesity treatment, delivered via the Rx Weight Loss (RxWL) program, produces clinically significant initial weight losses. However, the program's pragmatic utility in routine medical care has yet to be tested. Further, additional research is needed to determine how best to extend the RxWL program to facilitate weight loss maintenance. This paper summarizes methods for a pragmatic trial aimed at identifying optimal methods for implementation of RxWL in primary care and evaluating relative effectiveness of two approaches to weight loss maintenance. Study designRxWL will be implemented in a network of approximately 60 primary care clinics. Implementation outcomes (program uptake and completion metrics) will be compared between a Basic Implementation Intervention consisting primarily of access to RxWL, and an Enhanced Implementation Intervention with additional training in strategies for motivating and supporting patients in their use of RxWL and online clinician support tools for tracking patient progress. Second, two intervention approaches (Monthly Lessons versus Refresher Courses) within the RxWL patient platform will be tested against an educational control condition, and effects on 1-year weight loss maintenance will be compared. ConclusionThis study will provide essential information about the feasibility and utility of online obesity treatment in primary care. It will provide novel information on two approaches to weight loss maintenance for patients in this setting. This project fills key gaps in evidence regarding best practices for obesity treatment in primary care.

Effectiveness of an App and Provider Counseling for Obesity Treatment in Primary Care

Obesity treatment is less successful for socioeconomically disadvantaged populations, particularly when delivered in primary care. Digital health strategies can extend the reach of clinical obesity treatments to care settings serving patients at highest risk. Track was an effectiveness RCT of a 12-month digital weight-loss intervention, embedded within a community health center system. Participants were 351 adult patients (aged 21-65 years) with obesity and hypertension, diabetes, and hyperlipidemia. Patients were randomized to usual care (n=175) or an intervention (n=176) comprising app-based self-monitoring of behavior change goals with tailored feedback, a smart scale, dietitian-delivered counseling calls, and clinician counseling informed by app-generated recommendations, delivered via electronic health record. The primary outcome was 12-month weight change. Randomization began on June 18, 2013, final assessments were completed on September 10, 2015. Data analysis was conducted in 2016 and 2017. The trial retained 92% of usual care and 96% of intervention participants at 12 months. The Track intervention produced larger weight losses relative to usual care at 6 months (net effect: -4.4 kg, 95% CI= -5.5, -3.3, p<0.001) and 12 months (net effect: -3.8 kg, 95% CI= -5.0, -2.5, p<0.001). Intervention participants were more likely to lose ≥5% of their baseline weight at 6 months (43% vs 6%, p<0.001) and 12 months (40% vs 17%, p<0.001). Intervention participants completing ≥80% of expected self-monitoring episodes (-3.5 kg); counseling calls (-3.0 kg); or self-weighing days (-4.4 kg) lost significantly more weight than less engaged intervention participants (all p<0.01). A digital obesity treatment, integrated with health system resources, can produce clinically meaningful weight-loss outcomes among socioeconomically disadvantaged primary care patients with elevated cardiovascular disease risk. This study is registered at www.clinicaltrials.gov NCT01827800.

Low carbohydrate diet and obesity treatment in primary health care: dietary advice after the new Swedish report

In 2013, the Swedish Council on Health Technology Assessment (SBU) published a report “Dietary treatment of obesity” where low carbohydrate diet (LCD) was established as one of the evidence based diet options in obesity treatment, even without diabetes. No data exists on how much the health care professionals (HCP) in primary care actually are informed of or to which extent they use the knowledge in the new report. We aimed to investigate the HCPs’ current knowledge, attitudes and application of LCD in obesity treatment in primary care. All primary health care centres (PHCC) in Jonkoping County Council (JCC) were invited to participate in this cross sectional descriptive study. HCPs who were working with obese patients were sent an online survey by email from January to March 2014. Data was collected about self-estimated knowledge, clinical practice of dietary advice and attitudes on LCD as well as demographic data and work related information. Chi2 and logistic regression were used to analyse associations between the independent and the outcome variables. Two hundred and seventy-one HCPs completed the survey (70.7 %); 95 % gave dietary advice. Those who gave dietary advice, 49 % were uncertain about evidence based dietary advice; 28 % received education on dietary advice last year; 60 % reported patient requests for LCD; 80 % felt hesitant about LCD; 54 % stated that they have good knowledge about LCD and 47 % recommended LCD. Factors that influenced the advisement on LCD were profession (physician and diabetes nurse), patient requests for LCD (OR 0.46, 95 % CI 0.27-0.77, p = 0.003) and good knowledge (self-estimated) about LCD (OR 0.43, 95 % CI 0.26-0.71, p = 0.001). Recent education on dietary advice affected in a positive way the uncertainty about evidence based dietary advice (OR 0.19, 95 % CI 0.10-0.37, p = 0.0001), the hesitancy about LCD (OR 0.37, 95 % CI 0.20-0.71, p = 0.002) and self- estimated knowledge about LCD (OR 2.67, 95 % CI 1.49-4.80, p = 0.001). HCPs were positive to dietary advisement but had an ambivalent attitude toward LCD as yet another dietary option. This area may be improved with continuous educational training, supposing that this is prioritized. Thus, it is reasonable to believe that LCD will gradually be more common as a tool to deal with obesity in primary care in the future.

Intensive behavioral treatment weight loss program in an adult primary care practice.

To evaluate a nurse practitioner (NP) led intensive behavioral treatment program for obesity implemented in an adult primary care practice. The outcome variables for this study included weight loss as well as patient and provider ratings about program satisfaction, feasibility, and acceptability. Data sources were the patient medical records, patient satisfaction surveys, provider satisfaction surveys, and a provider focus group. Thirty-six eligible patients completed the program. The program was feasible and effective with statistically significant weight loss (mean weight loss 6.7 lbs after four visits and 10.7 lbs at 12 weeks) and clinically significant with 39% of patients losing 5% or more of body weight at 12 weeks, with a high degree of acceptance. Obesity is a national epidemic with significant health and economic consequences. The Centers for Medicare and Medicaid Services recognizes intensive behavioral therapy for obesity treatment in primary care and the U.S. Preventive Services Task Force established evidenced-based program criteria. However targeted interventions to treat obesity are largely lacking in primary care. NPs with a focus on patient-centered and evidence-based care are well positioned to lead intensive behavioral therapy initiatives for obesity treatment.

Provider Views of the Feasibility and Utility of Lifestyle Obesity Treatment in Primary Care: Insights from the Think Health! Study

Rationale: Feasible approaches for providing obesity treatment in primary care settings have been difficult to identify. We assessed the views of primary care clinicians and practice staff about a simplified, lifestyle weight loss program after their participation in a randomized trial designed to evaluate the program within their clinical practices. Methods: Post-hoc interviews were conducted with 13 clinicians and 12 auxiliary staff at the 5 participating practices in the Think Health! Study of weight management in primary care. A 13-item survey was used to guide semi-structured interviews about the perceived strengths, weakness, and potential long-term utility of the program. Responses were analyzed using descriptive statistics and qualitative methods. Results: Providers unanimously endorsed the need for weight loss counseling for their patients. They supported the need for more frequent visits initially to best engage patients in a weight loss program. Additional training in counseling skills was desired. Conclusion: Clinicians participating in a practice- based trial valued having weight loss materials available to share with patients. Offering patient materials that convey key content and structure for behavior change tasks while allowing provider discretion in how materials are integrated into patient care might be a viable option for testing in future practice-based research.

Combination Phentermine/Topiramate for Obesity Treatment in Primary Care: A Review

The treatment of obesity is often met with a myriad of challenges in the primary care setting. Nevertheless, a modest 5% weight loss is considered clinically significant and may be associated with health benefits. Phentermine/topiramate (Qsymia), available in the United States since September 2012, achieves clinically meaningful weight loss along with improvements in weight–related comorbidities. This combination drug therapy could be an additional tool for primary care providers in their quest for effective management of obesity. Special precautions and close monitoring are indicated when prescribing phentermine/topiramate for women of childbearing potential. Monitoring of heart rate and psychiatric and cognitive side effects is important.

A Chronic Care Model Program Incorporating Group Office Visits for Obesity Treatment in Primary Care

Background. Obesity is a chronic disease of epidemic proportions. Primary care providers are on the front line of diagnosing and treating obesity and need better tools to deliver top-notch obesity care. Methods. A pilot randomized trial was conducted to test a chronic care model (CCM) program for obesity compared to usual care. Primary care patients, 18 years and older, with a body mass index (BMI) between 27 and 45 were enrolled. Sixteen weekly 90-minute group office visits were structured with the first 30 minutes encompassing individualized clinical assessments and the final 60 minutes containing the group-based standardized intensive lifestyle training. The primary outcome was weight change at 16 weeks. Secondary outcomes were weight change at 24 weeks, change in diet and physical activity behaviors, self-efficacy for weight control behaviors, and physiologic markers of cardiovascular risk at 16 and 24 weeks. Results. The participants (19 in the active arm and 10 in the control arm) were 49.8 ± 11.5 years old (mean ± SD), 97% women, 55% white, and 41% black. Weight change in the control arm at week 16 was 0.25+ 2.21 kg (mean + SD) and that for the active arm was -5.74 + 4.50 kg (n=16). The difference between the two arms was significant (p = 0.0002). Both the intent-to-treat analysis using the last observation carried forward approach and the analysis including completers only provided similar siginificant results. Conclusions. This study demonstrated that a CCM program incorporating group office visits was feasible and effective for obesity treatment in primary care settings.

Obesity Treatment in Primary Care — Are We There Yet?

The U.S. Preventive Services Task Force recommends that clinicians arrange for their obese patients to receive intensive, multicomponent behavioral weight-loss counseling.1 However, less than 50% of primary care physicians (PCPs) report that they consistently provide diet and weight-control advice to their adult patients with weight-related disease, and less than 25% regularly refer patients for further management or track their weight-control behaviors over time.2 Recognizing the need for effective weight-management treatments that can be implemented in the primary care setting, the National Heart, Lung, and Blood Institute funded the Practice-based Opportunities for Weight Reduction consortium,3 a group of independent but coordinated . . .

The obesity epidemic: can we turn the tide?

Obesity has reached epidemic proportions in the UK. It is important because of the associated co-morbidities, which include cardiovascular disease, type 2 diabetes, and osteoarthritis. The prevalence of obesity has...