Despite the popularity of countless diet books and medical warnings about the dangers of excess weight, Americans are fatter than ever. More than two in three are now overweight, and over 30 percent are downright obese, according to the National Institutes of Health. It’s far more than a your-jeans-feel-tight or a not-ready-for-bathing-suit-season problem, too. The overweight and obesity epidemic is linked to an increased risk of type 2 diabetes, high blood pressure, heart disease, several cancers and other health problems.
The U.S. Preventive Services Task Force (USPSTF) recommends primary care doctors screen all adults for obesity and offer or refer their obese patients to a tried-and-true method of weight loss — intensive behavioral therapy. A multicomponent weight-loss intervention, the therapy includes individual and sometimes group counseling to help the overweight set goals, improve diet and nutrition, increase physical activity, and learn to overcome personal barriers to a healthy lifestyle. It also helps people actively self-monitor their diet and exercise. When this approach is followed, the result is an average weight loss of between about 8 and 16 pounds over the course of a year, according to the USPSTF.
To encourage primary care doctors to provide this effective weight-loss treatment, the Centers for Medicare and Medicaid Services (CMS) approved Medicare and Medicaid payments to doctors for intensive behavioral weight loss therapy. The CMS regulations stated the treatment must be provided by doctors, nurse practitioners, clinical nurse specialists, and physician assistants and consist of approximately 14 face-to-face, 10- to 15-minute sessions over six months.
In addition, the Guidelines for the Management of Overweight and Obesity in Adults, a position paper issued jointly by the American Heart Association, the American College of Cardiology, and the Obesity Society in 2013, recommended a similar approach — comprehensive behavioral weight-loss counseling with specific diet and exercise prescriptions.
With so much official support for intensive behavioral therapy, you might expect this form of weight-loss help to be widely studied and used. Surprisingly, that’s not the case.
There is little evidence primary care doctors are providing intensive behavioral therapy, according to a comprehensive review of the subject by researchers from the Perelman School of Medicine at the University of Pennsylvania. They found only 12 high-quality studies that examined behavioral therapy for obesity in patients encountered in primary care settings — but not one study involved primary care doctors who followed CMS guidelines.
“Only two studies identified counseling interventions that produced an average loss of at least five percent of initial body weight, an amount likely to improve weight-related health complications,” said Thomas A. Wadden, PhD, director of Penn’s Center for Weight and Eating Disorders and the review’s lead author.
In a single study that came close to meeting CMS standards, a registered dietitian and an exercise specialist worked together in a large primary care medical practice to provide intensive behavioral therapy. Overweight and obese patients had face-to-face group counseling sessions for 12 weeks, followed by twice monthly telephone or e-mail contacts. Almost two-thirds of the participants lost 5 percent of their initial weight, dropping an average of 15 pounds in six months. “These are impressive results for the number of treatment visits provided, and weight losses were well maintained over two years,” said Wadden.
The researchers concluded doctors could and should learn to provide intensive behavioral therapy. However, they noted doctors are often pressed for time and might prefer sending overweight patients to other weight-loss specialists for the therapy. Primary care doctors often have limited training in these strategies, as well.
“A variety of trained interventions potentially could deliver effective, evidence-based weight-loss counseling to the millions of Americans who would benefit from it,” Wadden. “Primary care practitioners cannot be expected to go it alone in reducing our nation’s waistline.”
There could be another reason, in addition to time constraints, why some doctors haven’t embraced intensive behavioral therapy as standard care for the overweight — fat prejudice. Health professionals often express biased opinions toward people with obesity, and these attitudes can impair the quality of healthcare they provide, according to a report by George Washington University (GWU) researchers.
"Many health professionals view people with obesity as lazy or lacking in willpower," said William H. Dietz, MD, PhD, director of the Sumner M. Redstone Global Center for Prevention and Wellness at GWU’s Milken Institute School of Public Health. "The disrespect shown by some providers may discourage future visits or delay essential care that could lead to weight loss or the detection of diseases associated with obesity."
Dietz and his colleagues concluded training for health professionals should emphasize it is not a lack of willpower but other complex factors that contribute to people becoming overweight and obese. They also urged health professionals to examine their attitudes towards obesity and to rely on new evidence-based strategies to care for overweight patients.
April 15, 2015
Christopher Nystuen, MD, MBA