Obesity Counseling in Primary Care

Articles from NEJM

A Two-Year Randomized Trial of Obesity Treatment in Primary Care Practice 

by Wadden et al.

Practice Based Opportunities for WEight Reduction (POWER) Trial at Penn.
Enhanced weight-loss counseling (quarterly PCP visits combined with brief monthly sessions with lifestyle coaches who instructed participants about behavioral weight control PLUS meal replacements or weight-loss medication (orlistat or sibutramine)) helps about one third of obese patients achieve long-term, clinically meaningful weight loss.

Comparative Effectiveness of Weight-Loss Interventions in Clinical Practice

by Appel et al.

In two behavioral interventions, one delivered with in-person support and the other delivered remotely, without face-to-face contact between participants and weight-loss coaches, obese patients achieved and sustained clinically significant weight loss over a period of 24 months.

Obesity Treatment in Primary Care — Are We There Yet?

Editorial by Dr. Yanovski

Wadden study: "Although weight loss in the brief-lifestyle-counseling group (2.9 kg) and the usual-care group (1.7 kg) did not differ significantly at 2 years, participants in the enhanced-lifestyle-counseling group lost significantly more weight (4.6 kg) than did those in either of the other two groups and were more likely to lose at least 5% of their initial body weight (35% in the enhanced-lifestyle-counseling group, vs. 26% in the brief-lifestyle-counseling group and 22% in the usual-care group)."

Appel study: "Weight loss at 2 years was similar in the groups that received in-person support (5.1 kg) and remote support (4.5 kg) and was significantly greater than the weight loss in the control group (0.8 kg). Participants assigned to either the in-person or the remote lifestyle intervention were twice as likely as those assigned to the control group to have lost 5% or more of their initial body weight at 2 years (41% for the in-person group and 38% for the remote group, vs. 19% for the control group)."

"A well-recognized issue that affects the sustainability of behavioral interventions is that attendance at face-to-face counseling sessions decreases substantially over time."

"Given that remotely delivered coaching resulted in weight-loss outcomes similar to those of in-person visits, the use of mobile technologies to deliver behavioral weight-loss treatment in primary care appears to be promising. Such interventions may present fewer barriers to adherence than interventions delivered in person, since they allow for greater scheduling flexibility, decreased travel time, and lower transportation costs. In addition, a telephone-based coaching program has the potential for widespread implementation in multiple practice settings, including geographically isolated areas."

"Determining the costs and cost-effectiveness of these and other treatments in primary care settings is crucial. In addition, these two studies were not powered to detect differences in cardiovascular risk reduction, and there were no consistent between-group differences with respect to lipid levels, glucose levels, or blood pressure at 2 years."

MEDICARE COVERS SCREENING AND COUNSELING FOR OBESITY

The services will be free to beneficiaries — the Medicare deductible and co-pay will not apply.

(From Medscape) Medicare patients are eligible for "intensive behavioral therapy for obesity" from primary care providers — nonphysicians included — in a primary care setting if their body mass index (BMI) is 30 kg/m2 or more. They are entitled to 1 face-to-face counseling visit each week for a month, followed by a face-to-face session every other week for an additional 5 months.

If a patient has lost at least 6.6 pounds during the first 6 months of counseling, he or she is entitled to an additional visit every month for another 6 months. For patients who fail to lose the required weight, "a reassessment of their readiness to change and BMI is appropriate after an additional 6-month period," according to CMS.

Specific services reimbursable under Medicare include an obesity screening, an assessment of the patient's diet, and behavioral counseling and therapy to promote sustained weight loss through diet and exercise. This course of treatment does not include medications for losing weight. CMS noted that the US Preventive Services Task Force had omitted medication from its recommendation for obesity screening and therapy for adults because of concerns about adverse drug events and lack of evidence about patients maintaining their weight after they stop taking such medications.

It remains to be seen what Medicare will pay for obesity counseling. In a "decision memo" published online, CMS stated that it is in the process of establishing payment codes.