Introduction
Obesity is a significant public health concern, and while the U.S. Preventive Services Task Force recommends that primary care providers (PCPs) counsel obese patients about weight loss, this often doesn't occur. Understanding how to improve the role of PCPs in weight management is crucial. The Hopkins POWER trial explored this issue by examining the roles PCPs play in weight management interventions, and how these interventions can be better integrated into primary care practices. This article will look into the findings of the study, and related research on weight loss interventions.
The Hopkins POWER Trial: A Model for PCP Involvement
The Hopkins POWER trial was a randomized controlled trial designed to assess the effectiveness of two behavioral weight loss interventions over a 24-month period in obese primary care patients who had at least one cardiovascular risk factor. The trial involved 415 participants with a mean age of 54.0, with 63.6% being women and 41% being black.
In this trial, PCPs had an explicit role: they screened for, publicized, and recommended the study to eligible patients, reviewed weight progress reports during routine patient encounters, used the report to motivate and support their patients, and re-engaged them in the program if not fully participating.
Study Design
The Hopkins POWER trial featured three arms:
- Remote: Patients in this arm received coaching over the phone without any in-person contact with coaches.
- In-person: This arm offered face-to-face group and individual sessions, as well as telephone contact with coaches.
- Control: Participants in the control arm met with a weight loss health coach at the time of randomization and, if desired, after the final data collection visit.
Patients in both intervention groups had weight-loss health coaches who provided education and positive reinforcement, emphasizing self-monitoring of weight, reduction of calorie intake, and increased exercise.
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PCP Responsibilities
Six community-based practices partnered with Hopkins investigators in the trial. The practices’ office medical directors provided early input to broadly define the responsibilities of the participating PCPs and their practices, and met monthly during the study period. Over the 24-month trial, PCPs received two brief informational meetings about the trial, as part of usually scheduled practice meetings. PCPs initially received information about their expected roles and then had updates about the trial’s progress. Specifically, PCPs were asked to screen for eligible patients (obese and with a cardiovascular risk factor), refer them to the trial, and for patients in the intervention arms, to review weight progress reports sent via facsimile to the practice prior to the patient’s routinely scheduled visits. These reports contained a graph showing the patient’s self-reported weights, generic guidance for the PCP on how to counsel the patient to encourage progress and stay in touch with the program, and a comment box for the PCP to communicate with the health coach. Finally, if a patient was not actively participating in the assigned intervention, the health coaches sent letters on behalf of the PCP to encourage involvement.
Focus Group Findings: PCP Roles in Weight Management
To gain deeper insights into the PCPs’ experiences, five end-of-study focus groups were conducted with PCPs who had patients enrolled in the trial. These focus groups aimed to assess their roles in the trial, both within and beyond the intended design, and to gather recommendations for integrating the program more broadly into primary care settings. From the six participating community practices in the metropolitan Baltimore area, 46 PCPs had enrolled patients in the trial. We invited the 30 PCPs with four or more enrolled patients to participate in a focus group. We held five focus groups in June-August 2010, which was close to the end of the 24-month trial.
The focus groups identified five major themes related to the PCP’s role in patients’ weight management:
1. Referral and Endorsement
PCPs highlighted the importance of their referrals and endorsement of the study for their patients. Several PCPs remarked about their unusual success at enrolling male patients into the study, which they attributed to the PCPs’ endorsement as labeling it a ‘medical’ program. One PCP observed, “[Men] feel okay and [that they are] not just in a typical weight loss program. “…[It helps] to be in a structured program where you’re not only getting education, but you’re also being watched, you’re being observed. And of course having the primary care doctor there too adds to the level of accountability of the patient.
2. Providing Accountability
PCPs acknowledged that they provided accountability to their patients from a distance, with only periodic visits and updates, since they could not offer the same intensity of services provided by the health coaches. However, PCPs acknowledged that they provided accountability to their patients from a distance, with only periodic visits and updates, since they could not offer the same intensity of services provided by the health coaches.
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3. Cheerleading
Many PCPs described their role as a cheerleader, acknowledging the patients’ successes and supporting their efforts. When patients returned for routine interval visits, many described their role as a cheerleader, acknowledging the patients’ successes and supporting their efforts. One PCP described a visit with a patient and said, “I think my patient liked when I showed [him] the progress, the charts. “One of my patients lost a lot of weight, and he’s actually off all of his diabetes and blood pressure medicines now because of it. So my role: there was not only cheerleading, but also saying, look, we’ve got to stop some of these medicines. You’re going too low sometimes.
4. Limited Role in Weight Management
Overwhelmingly, PCPs described their role in the Hopkins POWER weight loss intervention as being very limited and peripheral to the main program, which was centered on one-on-one health coaching. Although they referred patients into the program and adjusted medications during follow-up visits, many PCPs described limited specific knowledge of the lifestyle changes their patients made and the content of the health coaching. “A couple of [my patients] wanted to talk about it a lot, so to them, I guess, it was important that I knew all the details. So it felt like, put them out into the study and now they’re your baby.
5. Maintaining Long-Term Relationships
PCPs reflected on their long-term primary care continuity relationships with their patients as providing a backbone to the success of the weight loss intervention. PCPs reflected on their long-term primary care continuity relationships with their patients as providing a backbone to the success of the weight loss intervention. “But I try to ask-because it’s often a continuous conversation over many years is to try to understand where they are right now: ‘How are your weight issues going? Another PCP described her long-standing relationship with her patients and that she cared for multiple generations in the family, which enabled her to have insight into the patient’s home life: “Most of my [patients in the trial] I’ve known for quite a long time, and take care of not only them, but other family members.
Integrating Weight Loss Programs into Primary Care: PCP Recommendations
The PCPs offered several recommendations for successfully integrating the Hopkins POWER intervention more widely into primary care practices.
Streamlining Communication and Feedback
Although PCPs concurred about being too busy to take on a larger role in weight management, they recommended improving the content and delivery of the communication with the coaches if the program was scaled up. They suggested more accessible (e.g. available online), actionable and individualized feedback from the coaches that they could quickly obtain at the time of visits. They suggested more accessible (e.g. available online), actionable and individualized feedback from the coaches that they could quickly obtain at the time of visits.
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Financial Considerations
The majority of PCPs desired to maintain a peripheral management role in a larger scale of a program, similar to their stated experience with the study as described above. Their rationale was that the coaches were perceived as providing highly effective weight counseling and management, and the PCP had neither the time nor specific skill set.
Liraglutide for Suboptimal Weight Loss After Metabolic Bariatric Surgery
Another study investigated the use of liraglutide, a glucagon-like peptide 1 (GLP-1) receptor agonist, for weight loss in patients with suboptimal results after metabolic bariatric surgery (MBS). This prospective, double-blinded, single-center randomized clinical trial compared the effect of daily liraglutide with placebo in adults treated at an academic surgical department.
Study Design and Participants
Patients with anatomically correct adjustable gastric band, sleeve gastrectomy, one anastomosis gastric bypass, or Roux-en-Y gastric bypass (confirmed with barium swallow and/or endoscopy) were invited to participate at 12 to 36 months after surgery if they had a body mass index greater than 35 (calculated as weight in kilograms divided by height in meters squared), were aged 20 to 65 years, and had achieved a stable weight (defined as a weight consistently within a 4-kg range during a 3-month period) with an excess body weight loss (defined using body mass index threshold of 25) of 25% to 40% or total body weight loss of 5% to 12% for anatomically correct adjustable gastric band and excess body weight loss of 25% to 60% or total body weight loss of 10% to 20% for sleeve gastrectomy, Roux-en-Y gastric bypass, and one anastomosis gastric bypass. The first participant was randomized on January 18, 2019, and the last on June 9, 2023. Study intervention was liraglutide or placebo self-administered daily by participants. Participants self-titrated dosing. The study included 24 participants in each arm (liraglutide arm: mean [SD] age, 48.7 [10.5] years; 22 [92%] female; placebo arm: mean [SD] age, 43.6 [11.4] years; 20 [83%] female).
Key Findings
At 12 months, mean (SE) weight loss in the liraglutide group was 5.7 (1.1) kg with a mean (SD) weight gain of 1.4 (1.2) kg in the placebo group (between-group difference, 7.1 kg [95% CI, 3.9-10.3 kg]; P < .001). The mixed-effects model showed consistent weight loss in the liraglutide group (Figure 2A and B) during the study period. In this randomized clinical trial, liraglutide provided greater weight loss at 12 months than placebo in a cohort of patients with a suboptimal response to MBS. This suggests a role for OMMs for suboptimal weight loss after MBS, potentially avoiding riskier conversion MBS.
Implications
This study highlights the potential of obesity management medications (OMMs) like liraglutide in addressing suboptimal weight loss after MBS, offering a less invasive alternative to conversion surgeries.
Broader Perspectives on Weight Loss and Health
It is important to note that weight loss is not the only determinant of health. Some experts emphasize the importance of self-compassion, addressing underlying psychiatric conditions, and finding pleasure in movement, suggesting that physiological parameters can improve independently of weight loss.
Additionally, research indicates that cardiovascular fitness (CRF) plays a crucial role in mitigating mortality risk among overweight and obese individuals. A meta-analysis revealed that overweight or obese individuals with higher CRF did not have a higher risk for all-cause or CVD mortality compared to normal-weight, fit individuals.