Obesity continues to cast an enormous human and economic toll. A significant percentage of adults are considered overweight [e.g., body mass index (BMI) ≥25 kg/m2] and a substantial portion have obesity (e.g., BMI ≥30 kg/m2), collectively costing the health care system approximately $1.7 T annually. Despite the fact that obesity is both treatable and preventable, treating the comorbidities, rather than obesity per se has been the mainstay of therapy. Reasons for lack of weight management prioritization are extensive and complex but have included lack of clinician education on effective obesity management and processes that systematically address weight loss and weight loss maintenance long-term.
The Role of Primary Care in Weight Management
Most people receive their health care in primary care-not by specialists, dieticians, or health coaches-the vast majority of whom fail to maintain a normal body weight. Patient demand is high for weight management in primary care. A study reported that most patients want to discuss weight loss with their physicians. Specifically, patients value physician direction with their diet, physical activity, and goal setting. Weight loss interventions administered by a primary care provider can lead to modest weight loss. The current analysis examined what has been done in primary care for weight management.
What kind of programs are generally used?
Interventions ranged from provider use of newly reinforced knowledge in the area of behavior modification to multi-faceted approaches that included intensive behavioral therapy, anti-obesity medications, and meal replacements.
Effectiveness of Primary Care Weight Loss Interventions
Weight loss observed in clinical trials has failed to translate into real-world clinical settings. A systematic review and meta-analysis was conducted using several databases from inception to a specific date. The objective of the current systematic review and meta-analysis is to determine weight loss in randomized clinical trials specifically conducted in a primary care setting where a primary care provider administered the intervention for at least 6 months. Randomized clinical trials were included in this meta-analysis if they were conducted in a primary care setting with the primary care provider (physician, physician assistant, or nurse practitioner) administering the intervention for at least 6 months.
Details of the Meta-Analysis
The search strategy was designed in consultation with an experienced medical librarian with input from study investigators using various databases from inception to September 5, 2022. Based on the search terms, a large number of studies were imported for screening. After removing duplicates and studies that did not align with the primary outcome, only a small number of studies met the full inclusion criteria. Most studies were conducted in people with obesity who also had risk factors for poor outcomes (i.e., high-risk race/ethnicity, pre-existing type 2 diabetes, prediabetes, hypertension, dyslipidemia, or the metabolic syndrome).
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Key Findings
Major findings from the current analysis show that patients lose ~3 kg (approximately 3% body weight) when they are provided more than usual care by their primary care provider and that the amount of weight loss approximates 6 kg (roughly 6% body weight) when anti-obesity medication is part of the intervention.
A random effect model estimated a treatment effect for the aggregate efficacy of primary care interventions. There was evidence of substantial heterogeneity. Funnel plot analyses suggested the presence of publication bias. In univariate multilevel modeling, there was evidence for attenuation of the treatment effect with time, i.e., a reduction in weight loss of about 0.5 kg per 6 months.
The Role of Medication
Interventions that included a medication component (either alone or as components of multipronged intervention) achieved a greater weight reduction by −2.94 kg. In multivariate multilevel meta-regressions that included both covariates (type of intervention and duration of the intervention), the estimated weight loss associated with a drug component was identical to that estimated by the univariate model.
Components of Effective Weight Loss Programs
Effective weight loss programs often incorporate several key components:
- Lifestyle Advice: Patients value physician direction with their diet, physical activity, and goal setting.
- Medications for Weight Loss: Medications for weight loss are being more extensively studied and demonstrating improved outcomes. Medications that control feelings of hunger can often help you stick with a new eating plan. Medications are a tool for weight loss and work best when used as part of a comprehensive weight management plan that includes dietary changes and exercise.
- Bariatric Surgery: Bariatric surgery provides a possible option to address weight and reverse potentially life-threatening conditions such as heart disease and diabetes in both adolescents and adults.
- Intensive Behavioral Therapy (IBT): IBT for obesity is now a covered benefit under Medicare.
- Meal Replacements: Meal replacements can be an effective tool for choosing nutritionally balanced, low-calorie foods. They offer a convenient and controlled way to manage calorie intake while ensuring nutritional needs are met. When used as part of a structured program, under the supervision of one of our weight management providers, meal replacements can help to achieve and maintain weight loss goals.
Additional Strategies and Tools
- Measurement, Education, and Individualized Assistance: These include nutrition, physical activity, behavioral modification, metabolism and body composition assessment, anti-obesity medications, and adjustments to your current medications.
- Mindful Eating and Nutrition Planning: Mindful eating is a cornerstone of care. This involves discussing eating habits, triggers, and distinguishing between "head hunger" and true metabolic needs.
- Self-Monitoring Tools: The bathroom scale, food diaries, and label reading can all help you reach your weight loss goals and maintain a healthy weight.
- Exercise Guidance: Providers help set exercise goals that are aligned with your current fitness level and that can be used at your local gym, at home, or in the community.
Weight Management Programs: Examples and Approaches
Comprehensive Obesity Management Program (COMMP)
COMMP utilizes evidence-based medicine to achieve successful weight loss and improve overall health. With a multidisciplinary team consisting of obesity medicine physicians and registered dietitians, every patient receives an individualized plan catered to their specific goals and needs.
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- Chronic Care Model: Just like diabetes, obesity is a chronic disease, and the relationship established between you and your COMMP Team lasts a lifetime.
- Treatment Frequency: For the first two months, patients visit the center every week, alternating visits between physicians and registered dietitians. After two months, visits are spaced out to fit the patient's schedule, and a plan is developed together to help succeed at long-term weight maintenance.
- Expected Weight Loss: Based on clinical studies in obesity, a typical expectation is to see patients lose 1-1.5% of their body weight per week, which is both safe and sustainable. For example, if you weigh 200lbs that is 2-3 pounds per week.
- Medication Considerations: For some patients with obesity or overweight issues and certain medical conditions, anti-obesity medications are prescribed to interrupt pathways in your body that drive obesity.
Weight Management Program at NYU Langone
People who are affected by obesity and have had limited success losing weight on their own may benefit from medically supervised weight loss through the Weight Management Program at NYU Langone. This program's nonsurgical medical weight loss methods focus on proper nutrition, physical activity, and making healthier lifestyle choices.
- Multidisciplinary Approach: The program works with you and your primary care physician, exercise experts, nutritionists, psychologists, and other specialty providers as necessary.
- Medical Evaluations: Many medical conditions can worsen as a person gains weight, and weight loss is often the best way to manage these conditions.
- Medication Review: Clinicians work with your primary care physician to suggest helpful strategies.
Cone Health Medical Weight Loss
When you have a lot of weight to lose, turn to the weight-loss experts at Cone Health. Your Cone Health medical weight-loss team understands-and targets-a wide range of factors that contribute to excess weight, including genetics, biology, medical issues, environment, and behavior.
Considerations and Collaborative Care
While you will see the team at COMMP more frequently than your primary care provider (PCP), the medical care they provide is not a substitute for other chronic disease care, sick visits, or your annual physical exam. All patients are encouraged to maintain a relationship with their PCP. As obesity medicine specialists, they are comfortable managing obesity and any weight-related conditions. In some cases, some medications prescribed by your PCP will need to be adjusted or discontinued. The goal is to collaborate with your PCP as your medication needs change.
Shifting the Paradigm in Obesity Treatment
There are reasons to believe, however, that the paradigm may be shifting. Clinical trials testing infrastructure for weight-prioritized visits in primary care coupled with highly effective pharmacotherapy may make patient weight loss of 15%-22% achievable.
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