Managing obesity in primary care practice: an overview with perspective from the POWER-UP study

Abstract

Primary care practitioners (PCPs) have been encouraged to screen all adults for obesity and to offer behavioral weight loss counseling to the affected individuals. However, there is limited research and guidance on how to provide such intervention in primary care settings. This led the National Heart, Lung and Blood Institute in 2005 to issue a request for applications to investigate the management of obesity in routine clinical care. Three institutions were funded under a cooperative agreement to undertake the practice-based opportunities for weight reduction (POWER) trials. The present article reviews selected randomized controlled trials, published before the initiation of POWER, and then provides a detailed overview of the rationale, methods and results of the POWER trial conducted at the University of Pennsylvania (POWER-UP). POWER-UP's findings are briefly compared with those from the two other POWER trials, conducted at Johns Hopkins University and Harvard University/Washington University. The methods of delivering behavioral weight loss counseling differed markedly across the three trials, as captured by an algorithm presented in the article. Delivery methods ranged from having medical assistants and PCPs from the practices provide counseling to using a commercially available call center, coordinated with an interactive website. Evaluation of the efficacy of primary care-based weight loss interventions must be considered in light of costs, as discussed in relation to the recent treatment model proposed by the Centers for Medicare and Medicaid Services.

Figure 1

Mean (±SE) weight loss (in kg) in participants assigned to Usual Care, Brief Lifestyle Counseling (Brief LC), and Enhanced Brief Lifestyle Counseling (Enhanced Brief LC). At months 6, 12, and 18, groups with different superscripts (i.e., a, b, c) differ significantly (p ≤ 0.05) from each other.

Figure 2

Mean (±SE) weight loss (in kg) in participants in Enhanced Brief Lifestyle Counseling who chose at the start of the trial to use sibutramine, meal replacements, or orlistat as their enhancement. (Participants may have changed enhancements during the study.) At months 6, 12, and 18, groups with different superscripts (i.e., a, b, c) differ significantly (p ≤ 0.05) from each other.

Figure 3

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).