'Enhanced' Counseling May Help Some Obese Patients

Marlene Busko

November 15, 2011

November 15, 2011 (Orlando, Florida) — About a third of obese patients who received "enhanced counseling"--monthly weight-loss counseling supplemented with meal replacements or a weight-loss drug--had 5% weight loss at two years, researchers report [1].

The Practice-based Opportunities for Weight Reduction Trial at the University of Pennsylvania (POWER-UP) was presented here Monday at the American Heart Association 2011 Scientific Sessions and is published online November 14, 2011 in the New England Journal of Medicine.

"The key finding is that primary-care practitioners working with medical assistants can help their obese patients loose a small but clinically meaningful amount of weight," lead author Dr Thomas A Wadden (University of Pennsylvania, Philadelphia) told heartwire . "A modest, 5% weight loss can reduce the risk of developing type 2 diabetes and improve other cardiovascular risk factors such as high triglyceride and LDL-cholesterol levels," he noted.

The study showed that " 'enhanced' lifestyle counseling can result in successful and meaningful weight loss . . . [and] is reasonable and realistic to implement in a more global way," Dr Marc-Andre Cornier (University of Colorado School of Medicine, Boulder) concurred, when asked to comment.

More Counseling, More Weight Loss?

To tackle obesity, the Centers for Medicare and Medicaid Services has recently proposed that primary-care providers offer obese seniors 14 behavioral counseling visits over six months, Wadden noted. "This is great, although other health professionals, including medical assistants or registered dietitians, probably could provide behavioral counseling at a lower cost than physicians and nurse practitioners," he added.

In a pilot study to assess the effectiveness of brief counseling by trained medical assistants vs usual care, his team found that obese patients lost about 4.4 kg in six months.

This study added a third arm in which counseling was enhanced by a diet drug or meal replacement, each of which is known to increase weight loss by about 3 to 5 kg.

Investigators recruited adults with a body-mass index of 30 to 50 kg/m2 at six primary-care practices, starting in January 2008. The 390 participants (80% women) had a mean age of 52 years and a mean weight of 108 kg.

Each participant received a balanced diet plan, pedometer, calorie-counting book, educational handouts, and instructions to reach three hours of physical activity a week. Participants were randomized to:

  • Usual care: A visit to their primary-care provider every three months, where weight management was discussed for five to seven minutes.

  • Brief lifestyle counseling: Usual care plus a monthly 10- to 15-minute visit with a "lifestyle coach."

  • Enhanced brief lifestyle counseling: Brief lifestyle counseling plus a choice of free sibutramine, orlistat, or Slim-Fast shakes or bars.

After sibutramine was removed from the market in October 2010, participants who were taking it switched to orlistat or meal replacement.

The primary outcome was weight change at two years in the two counseling groups vs usual care. Secondary outcomes included attaining a 5% or 10% weight loss at 12 and 24 months.

Shakes, Bars, and Counseling

Patients lost the most weight at one year and regained some by two years. Average weight loss at one year was 2.1 kg, 3.5 kg, and 7.0 kg with usual care, brief counseling, and enhanced counseling, respectively. At two years, average weight loss for these groups was 1.7 kg, 2.9 kg, and 4.6 kg, respectively.

Patient Outcomes at Two Years

Outcome Usual care Brief lifestyle counseling Enhanced brief lifestyle counseling p
Weight loss, kg 1.7±0.7 2.9±0.7 4.6±0.7 0.003
At least a 5% decrease in weight, % of patients 21.5 26.0 34.9 0.02

p=comparisons of enhanced brief lifestyle counseling vs usual care

"It is disappointing that brief lifestyle counseling . . . was not as effective as predicted [by the pilot study] at two years," Cornier said. The study authors surmise that this might be partly because only 56.1% of patients in this group vs 64.7% of patients in the enhanced-counseling group attended all 25 scheduled coaching sessions. "We . . . need to find ways to help improve patients' adherence to these types of interventions," Cornier said.

Patients in the enhanced-counseling group had some significant improvements in waist circumference, as well as HDL cholesterol and triglyceride levels, but the study was not powered to assess differences in cardiovascular risk factors.

Real-World Weight-Loss Model

The patients who chose to supplement counseling with meal replacement lost about nine pounds at two years, Wadden noted, adding that "this option does not present as many side effects as medication and is cheaper."

"Our study provides a model for in-person behavioral counseling," but ultimately many more weight management strategies may prove viable, including programs delivered by call centers or smart phones, he said. His group hopes to extend the study to four years and plans to make the 25 coaching lessons available on their website.

POWER-UP is just one of two studies at the AHA meeting supporting a role for some type of personal contact as a strategy for boosting weight-loss efforts. The unrelated POWER trial was presented in Tuesday morning's late-breaking clinical-trials session and also published simultaneously in the New England Journal of Medicine.

Author disclosures are available on the journal website. Cornier has no relevant disclosures.


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