Victor J. Stevens, Ph.D.
Kaiser Permanente Center for Health Research, Portland, Oregon
As the science of obesity treatment has developed, there has been a trend toward increasing the intensity and duration of behavioral treatments. Longer treatment duration generally results in greater weight loss, and more weight loss during treatment typically results in greater mean weight loss one and two years after treatment (1). The most effective behavioral treatments now include an initial six-month period of weekly group meetings lead by professional counselors, followed by monthly (or more frequent) group and individual follow-up contacts for another year or more.
While effective, a long series of weekly group meetings is expensive and can be a burden for participants. Many individuals are not able to attend such meetings due to work schedules, family care responsibilities, transportation problems or other barriers. Added to this list of problems is the reluctance of most health care insurance purchasers to fund such programs. No matter how effective we can make our intensive treatment programs, we must recognize that such programs cannot, by themselves, deal with the full scope of the obesity epidemic.
Reviewing the past 30 years of tobacco cessation research is instructive. Like obesity treatment, intensive tobacco cessation treatments are more effective than brief treatments. However, it is difficult to recruit more than a small proportion of smokers for intensive tobacco cessation programs, (2). In an attempt to reach the total population of smokers, a number of brief interventions have been developed. While less effective than the more intensive programs, they can be delivered at a much lower cost per participant, and therefore reach much large populations. Many of the most effective brief interventions for tobacco cessation have been designed for health care settings. Examples include simple physician advice to quit smoking (3), physician advice combined with brief counseling by a nurse or counselor in the medical clinic (2), brief provider advice combined with follow-up telephone counseling (4), and bedside counseling for hospital patients (5). All of these approaches, and many more, have been shown to be effective and cost-effective in randomized trials (6, 7).
The potential for brief counseling to prevent weight gain, weight loss, or maintenance of weight loss has not been extensively studied. We know that brief interventions can be effective in helping participants make dietary changes (8-11), and recent results from the PREMIER trial indicate that a brief weight loss intervention may help motivated participants lose modest amounts of weight (12).
It would be interesting to test various brief weight loss intervention strategies in managed care settings. Managed care programs have incentives to treat obesity, and have valuable resources that could be used in support of such interventions. The potential influence of focused, personalized advice from primary care physicians should be tested, both by itself, and in conjunction with various types of supportive counseling and follow-up contacts.
Note that many managed care programs have comprehensive medical records that could be used to build overweight and obesity registries. These registries could be used in a variety of ways to support population-based intervention programs. Another interesting feature of managed care plans is that patient weights recorded in the medical record can be used to evaluate both individually-based and population-based treatment programs. Currently, about 7% of managed care plans use comprehensive electronic medical records (13). This proportion is expected to grow to 50% or more within 10 years. Electronic medical records allow the potential for quickly and inexpensively assessing body weight and BMI in entire patient populations.
Ideally we would have a mix of services available for dealing with the obesity epidemic including a stepped care approach based in primary medical care. Such treatments would include a variety of approaches for prevention and early treatment, as well as more intensive treatment programs for more difficult cases. Much work needs to be done to determine the most effective and cost-effective strategies for simple treatments, and the most effective ways of combining treatments.
- Jeffery RW, Drewnowski A, Epstein LH, Stunkard AJ, Wilson GT, Wing RR et al. Long-term maintenance of weight loss: current status. Health Psychol 2000; 19(1 Suppl):5-16.
- Hollis JF, Lichtenstein E, Vogt TM, Stevens VJ, Biglan A. Nurse assisted counseling for smokers in primary care. Annals of Internal Medicine, 1993; 118:521-525.
- Kottke TE, Battista RN, DeFriese GH, Brekke ML. Attributes of successful smoking cessation interventions in medical practice. A meta-analysis of 39 controlled trials. JAMA. 1988 May 20; 259(19):2883-9.
- Stevens VJ, Severson H, Lichtenstein E, Little SJ, Leben J. Making the most of a teachable moment: A smokeless tobacco cessation intervention in the dental office. American Journal of Public Health, 1995; 85(2):231-235.
- Stevens VJ, Glasgow RE, Hollis JF, Lichtenstein E, Vogt TM. A smoking cessation intervention for hospital patients. Medical Care, 1993, 31(1):65-72.
- Fiore MC, Bailey WC, Cohen SJ, et al. Treating Tobacco Use and Dependence: A Clinical Practice Guideline. Rockville, MD: US Department of Health and Human Services, 2000. (http://www.surgeongeneral.gov/tobacco).
- Meenan RT, Stevens VJ, Hornbrook MC, La Chance PA, Glasgow RE, Hollis JF, Lichtenstein E, Vogt TM. Cost effectiveness of a hospital based smoking cessation intervention. Medical Care 1998; 36(5):670-678.
- Campbell MK, DeVellis BM, Strecher VJ, Ammerman AS, DeVellis RF, Sandler RS. Improving dietary behavior: The effectiveness of tailored messages in primary care settings. Am J Pub Health. 1994; 84:783-787.
- Brug J, Steenhuis I, van Assema P, de Vries H. The impact of a computer-tailored nutrition intervention. Prev Med 1996; 25(3):236-242.
- Beresford SA, Curry SJ, Kristal AR, Lazovich D, Feng Z, Wagner EH. A dietary intervention in primary care practice: the Eating Patterns Study [see comments]. Am J Public Health 1997; 87(4):610-616.
- Stevens VJ, Glasgow RE, Toobert DJ, Karanja N, Smith KS. One-Year Results from a Brief, Computer-Assisted Intervention to Decrease Consumption of Fat and Increase Consumption of Fruits and Vegetables. Preventive Medicine, 2003; 36:594-600.
- Appel LJ, Champagne CM, Cooper LS, Elmer PJ, Harsha DW, Lin PH, Obarzanek E, Stevens VJ, Svetkey LP, Vollmer WM, Young DR. Effects of comprehensive lifestyle modification on blood pressure control: Main results of the PREMIER clinical trial. JAMA, 2003; 289:2083-2093.
- Lynam KB, Billings E, Tolle S. Evaluating EMRs: Do?s and Don?ts in Implementation. Medical Group Management Association Annual Conference, San Antonio, TX; October 22, 2001.
- Stevens VJ, Corrigan SA, Obarzanek E, Bernauer E, Cook NR, Hebert P, Mattfeldt Beman M, Oberman A, Sugars C, Dalcin AT, Whelton PK, for the TOHP Collaborative Research Group. Weight Loss Intervention in Phase I of the Trials of Hypertension Prevention. Archives of Internal Medicine, 1993; 153:849-858.
- Stevens VJ, Obarzanek E, Cook NR, Lee IM, Appel LJ, Smith D, Milas CN, Mattfeldt-Beman M, Belden L, Bragg C, Millstone M, Raczynski J, Brewer A, Singh B, Cohen J, for the Trials of Hypertension Prevention Research Group. Long-term weight loss and blood pressure changes: Results of the trials of hypertension prevention phase II. Annals of Internal Medicine, 2001; 134:1-11.