Managing obesity in primary care practice: a narrative review

Abstract

This narrative review examines randomized controlled trials of the management of obesity in primary care practice, in light of the Centers for Medicare and Medicaid Services' decision to support intensive behavioral weight loss counseling provided by physicians and related health professionals. Mean weight losses of 0.1-2.3 kg were observed with brief (10- to 15-min) behavioral counseling delivered by primary care providers (PCPs) at monthly to quarterly visits. Losses increased to 1.7-7.5 kg when brief PCP counseling was combined with weight loss medication. Collaborative treatment, in which medical assistants delivered brief monthly behavioral counseling in conjunction with PCPs, produced losses of 1.6-4.6 kg in periods up to two years. Remotely delivered, intensive (>monthly contact) behavioral counseling, as offered by telephone, yielded losses of 0.4-5.1 kg over the same period. Further study is needed of the frequency and duration of visits required to produce clinically meaningful weight loss (>5%) in primary care patients. In addition, trials are needed that examine the cost-effectiveness of PCP-delivered counseling, compared with that potentially provided by registered dietitians or well-studied commercial programs.

Figure 1

An algorithm for identifying an appropriate weight loss option. After treating cardiovascular disease (CVD) risk factors and assessing patients’ activation for weight loss, primary care providers (PCPs) may elect to offer behavioral counseling themselves (with or without pharmacotherapy) or to provide collaborative care with other health professionals. Alternatively, PCPs may refer patients to community programs (e.g., Weight Watchers) or to obesity treatment specialists (e.g., medically supervised programs, bariatric surgery).

Figure 2

Change in weight over 24 months in three randomized groups. At month 24, enhanced brief lifestyle counseling resulted in significantly greater weight loss than did usual care (P = 0.003), with no other significant differences between groups. Reprinted from Ref. .

Figure 3

Mean weight change according to randomized group (Call-Center–Directed = remote support only; In-Person–Directed = in-person support; Self-Directed = control). At month 24, both intervention groups lost significantly more weight than the control group (P < 0.001), with no significant difference between the intervention groups. Reprinted from Ref. .