PCP’s instrumental to weight loss

On February 2, 2010, in Uncategorized, by Andrea

As much as docs (and, well, us) may not want to admit it, our PCP’s can be instrumental in helping with weight loss in the morbidly obese — and I don’t just mean in signing that Letter of Medical Necessity for surgery, either.  Let’s face it — not everyone is ready for surgery yet – maybe this is a step in helping some get ready for it.

From Medscape:

Primary Care Practice Intervention Can Prompt Weight Loss in Morbidly Obese

Nancy Fowler Larson

February 2, 2010 — Primary care practices can be instrumental in helping patients who are morbidly obese to lose weight and keep it off, according to a study published January 25 in the Archives of Internal Medicine.

“Other therapeutic techniques for treating obesity, besides surgery, including diet, exercise, behavior therapy, and pharmacotherapy, might be applied, but there are few data on applying them in cases of extreme obesity, despite it being commonly encountered,” write Donna H. Ryan, MD, from the Pennington Biomedical Research Center, Baton Rouge, Louisiana, and colleagues. “We developed the Louisiana Obese Subjects Study (LOSS) to test the hypothesis that primary care physicians could effectively implement intensive medical management to treat patients with extreme obesity, with a goal of weight loss at year 2 significantly better than usual care.”

LOSS, a randomized controlled pragmatic clinical trial, took place from July 2005 through January 2008. Volunteers, 83% of whom were women, had body mass indexes of 40 to 60 kg/m2 and a mean age of 47 years. They were divided into 2 groups: intensive medical intervention (IMI; n = 200) and usual care condition (UCC; n = 190). The UCC group was directed to an Internet weight loss program. The IMI faction was counseled by primary care practices to follow these recommendations:

  • Maintain a 900-kcal liquid diet for up to 12 weeks.
  • Attend group behavioral counseling, follow a standardized diet and exercise program, and take weight-loss medications (choice of sibutramine hydrochloride, orlistat, or diethylpropion hydrochloride) during months 3 through 7.
  • Continue medications and adhere to maintenance methods for months 8 through 24.

The retention rate was 51% for the IMI group and 46% for the UCC group (P = .30). Those who attended the final study visit received a $100 gift card.

Physician Support Results in Long-Term Weight Loss

After 2 years, the study authors reported that the IMI group had lost more weight and maintained their weight loss better than the UCC segment:

  • In the IMI group, 31% achieved a weight loss of 5% or more, and 7% achieved a 20% or greater weight loss vs 9% and 1%, respectively, in the UCC group.
  • A weight loss of −4.9% ± 0.8% in IMI and −0.2 ± 0.3% in UCC was demonstrated by the mean ± SEM baseline observation carried forward.
  • A weight loss of −8.3% ± 0.79% for IMI and −0.0% ± 0.4% for UCC was shown by the last-observation-carried-forward analysis.
  • The 101 IMI subjects who completed the study lost −9.7% ± 1.3% (−12.7 ± 1.7 kg); the 89 remaining UCC participants lost −0.4% ± 0.7% (−0.5 ± 0.9 kg).

The results were significant (P < .001) at year 2 for all group differences, according to the study authors, given that most of the morbidly obese population will not have weight loss surgery.

“Recently, the SOS [Swedish Obese Subjects] study demonstrated that surgery for obesity is associated with reduction in mortality,” the authors write. “Still, surgery is currently not an option for most patients with extreme obesity because of reimbursement issues and individual preference.”

In an interview with Medscape, John Morton, MD, director of bariatric surgery at Stanford University in Stanford, California, pointed out that, of the 12 million candidates for weight-loss surgery in the United States, fewer than 175,000 undergo such procedures each year. Dr. Morton noted several limitations to the Pennington study, including small sample size, modest weight loss, and high dropout rate. Still, he applauded the results as a forward step in obesity treatment.

“Obesity is a chronic disease and just like any chronic disease it requires a lot of different modalities, including surgery and other medical intervention,” Dr. Morton said. “Even a modest amount of weight loss is going to result in some significant health benefits.”

Physicians See Weight Loss Intervention as “Daunting”

An editorial, published in the same issue of the Archives, said primary care practices are in dire need of a boost to their confidence regarding obesity treatment. In his commentary, Robert F. Kushner, MD, from the Northwestern University Feinberg School of Medicine, Chicago, Illinois, said that obesity intervention is often seen by physicians as a “daunting or even futile task.”

“There are few other examples in medicine where stigmatization of the patient, feelings of being ill equipped, perceived treatment ineffectiveness, and even reluctance to engage in obesity care prevail as major barriers,” Dr. Kushner said.

However, primary care practices can play a valuable role in weight loss and control among morbidly obese patients, the study authors concluded.

“Primary care practices can initiate effective medical management for extreme obesity; future efforts must target improving retention and weight loss maintenance,” the authors write.

The Office of Group Benefits (OGB) for the State of Louisiana funded the study. Abbott Laboratories donated a portion of the sibutramine used in the study. The authors disclosed that OGB’s primary contractee, Pennington Biomedical Research Center, has received research funding from pharmaceutical companies including Abbott Laboratories, Roche, GlaxoSmithKline, Amylin, Johnson & Johnson, Arena, Hollis Eden, Eli Lilly and Co, Merck & Co, Pfizer, Sanofi-Aventis, Shionogi, Takeda Pharmaceutical Co, and Vivus. At the study’s onset, Dr. Kaj Stenlof was an employee of Pennington Management of Clinical Trials, which monitored the research. Fifteen of the 20 study authors receive, have received, or will receive health insurance from the OGB. Several of the study authors have been paid consultation and/or service fees, received grant money from, or hold stock in, Abbott Laboratories, Arena, Johnson & Johnson, Merck & Co, NutriSystem, Sanofi-Aventis, Shionogi, Vivus, Amylin Pharmaceuticals, Orexigen Pharmaceuticals, GlaxoSmithKline, Takeda, Bristol-Myers Squibb, AstraZeneca, Hoffmann-La Roche, Ethicon, Biovitrum, BMS, Global Health Partners, Lenimen, and/or NovoNordisk, all of which manufacture medicines involved in the study. Several of the authors have received salaries from the OGB-sponsored project. A full list of disclosures is available in the original article.

Arch Intern Med. 2010;170:124-125, 146-154.

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