Designing and implementing successful office-based weight-loss programs has been long advocated but challenging to translate into clinical practice.5,6
In the present report, we describe a successful weight-loss program in clinical practice focusing on assessment of cardiovascular risk factors (lipid disorders, blood pressure, diabetes, metabolic syndrome, and smoking) and lifestyle modification with diet and exercise. The program uses a dietitian at 2 visits. The dietitian is fully reimbursable for obesity (billing codes 278.0 and 278.01), overweight (278.02), and dyslipidemia (272.0). This has important implications for cost effectiveness because no group sessions, which are expensive and time consuming, were involved. This approach should be feasible for use by primary care physicians to achieve weight loss in the outpatient setting when a dietitian is present.
A strength of this study is the significant weight loss and its long-term maintenance. The importance of modest, long-term maintained weight loss has been previously endorsed.7–9
In the present program, 64 obese patients lost 5.6% of total weight at a mean follow-up of 1.75 years. Most importantly, 81% of them maintained an average 5.3% weight loss at average follow-up of 2.6 years. Those maintaining their weight loss exercised more days per week than did those who did not, a finding emphasizing the importance of exercise in maintaining weight loss. This is particularly important because weight stability after weight loss has been shown to play an important role in modifying the relation between cholesterol and heart disease.10
Interestingly, in the present program, weight loss was accomplished with a greater focus on modification of cardiovascular risk factors with diet and exercise and less emphasis on patients’ weight. Weight loss was accompanied by dramatic improvement in lowering triglycerides (average 34%), increasing HDL cholesterol (average 9.6%), and decreasing LDL cholesterol (9.3%). Thirty-five percent of patients were started on lipid-lowering drugs; thus, the decrease in LDL cholesterol may be partly attributable to drug therapy; however, the increase in HDL and decrease in triglycerides are greater than predicted with statin therapy and are more likely to result from the exercise and weight-loss components.
How feasible would it be for primary care practices to adapt this strategy? Data such as those from the multicenter Activity Counseling Trial (ACT) showed the feasibility of training clinicians to integrate 3 to 4 minutes of physical activity advice into routine office visits of sedentary adult patients.11
Clinicians’ response to the ACT was positive and participation in the study was viewed as minimally disruptive to clinicians and beneficial to patients. Moreover, trials such as the ACT demonstrated success with patients without clinical cardiovascular disease.12
In a primary care setting, office staff can help perform anthropometric measurements including height, weight, and waist circumference, calculate body mass index from a nomogram, and prompt, co-ordinate, and deliver counseling and follow-up services.1
On the basis of our results, we suggest that primary care physicians hold an “obesity” clinic on prespecified days and arrange for a dietitian to be available at those sessions, a situation similar to that described in this report.
Modest weight loss ≤10% has been shown to have beneficial health effects.7,8
Most patients in our study were seen in follow-up at 6 months after the initial visit and then at 1 year. We predict that earlier follow-up (i.e., at 3 months), more frequent follow-up (i.e., every 3 months), and monthly telephone check-ins concerning diet, exercise, and weight-loss logs would result in earlier and greater weight loss. Given the prevalence and consequences of overweight and physical inactivity, helping even a small percentage of patients improve their weight and daily activity may lead to a public health effect. It is therefore critical that weight-loss interventions with proved success in a clinical setting be disseminated and eventually implemented by more clinicians.