The provision of behavioral weight loss counseling by PCPs and auxiliary health providers in primary care practices has met with limited success, in most cases producing mean weight losses of only 1–3 kg in 6–24 months of intervention. These modest weight losses are most likely attributable to infrequent treatment contacts, typically at monthly to quarterly intervals, as well as to the brief duration of visits, usually 10- to 15-min sessions. This low intensity of treatment may be all that can be readily accommodated in busy outpatient practices, in which providers must respond to a variety of acute illnesses that may seem more pressing than obesity.
The low-intensity treatments tested in primary care settings contrast sharply with the weekly group and individual interventions (with 30- to 90-minute sessions) that have been delivered by weight loss specialists (e.g., registered dietitians, psychologists) in academic medical centers and that have produced mean losses of 7–10% of initial weight. It is not fair to compare the results of (underfunded) pilot studies conducted in primary care with findings from costly efficacy trials that often are implemented without sufficient thought concerning whether the intervention can be widely disseminated. However, the efficacy trials do tend to underscore the importance of frequent patient-provider contact (i.e., high-intensity interventions), as revealed by the task force's review.13
CMS's mandate that primary care providers offer high-intensity behavioral interventions to their obese patients, thus, seems appropriate, given the importance for weight loss of frequent patient-provider contact. CMS's provision of 14 counseling sessions during the first six months is close to the 16 visits provided in the DPP in the first six months, at which time participants lost a mean of 7 kg. However, the decision to provide 15-min visits with PCPs, rather than the 30-min sessions used in the DPP, is not supported by sufficient evidence demonstrating the efficacy of the shorter visits. Moreover, as revealed by the present review, there is little evidence that physicians, NPs, and PAs can help most obese patients achieve clinically meaningful weight losses (≥5% of initial weight). The study by Ashley et al.
reviewed above, comes closest to meeting CMS's proposed treatment paradigm. For one year, patients had brief (10- to 15-min), every-other-week visits with a physician or nurse who provided behavioral weight loss counseling (following the LEARN Manual), combined with the use of meal replacements (provided free of charge). Participants lost a mean of only 3.5 kg at the end of the year, despite being provided the 26 office visits and the meal replacements, the latter which usually increase weight loss by 30% or more compared with the consumption of a conventional reducing diet.
Physicians, NPs, and PAs in primary care undoubtedly could be instructed in delivering effective behavioral weight loss counseling, in the same manner that auxiliary health professionals were trained to do so in several of the studies reviewed above. However, other professionals, particularly registered dietitians, already possess the knowledge and skills required to provide effective behavioral counseling and can do so at a substantially lower cost than physicians and the other providers currently approved by CMS. Ultimately, physicians and their health care practices must decide whether they can afford to spend their time providing behavioral weight loss counseling, with its demand for weekly and then twice-monthly sessions for the first six months. Practices would have to hire more physicians, NPs, and PAs to provide routine medical care to patients whose former PCPs’ schedules were now filled delivering behavioral weight loss counseling. Hiring registered dietitians and other lifestyle interventionists to counsel obese patients would appear to make more economical sense for primary care practices, integrated health systems, and CMS than deploying physicians, NPs, and PAs in this effort.
Remotely delivered, high-intensity behavioral weight loss counseling was perhaps the most promising approach identified by this review. Appel et al.47
found that 12 weekly telephone sessions (20-min), followed thereafter by monthly calls, induced a mean loss of 6.1 kg at six months and of 4.6 kg at 24 months. These losses were equivalent to those of participants who were offered a traditional face-to-face intervention that combined group and individual visits. Participants in Appel's study also received an Internet-based program. However, additional trials, conducted outside of primary care practices which used telephone-counseling alone, have found equivalence of this approach with comparable on-site interventions.45,46,61
Remotely delivered lifestyle counseling, whether provided by a primary care practice, or by a call center with which it has contracted, would appear to be a very convenient option for patients. More important, it would support PCPs in their efforts to offer intensive behavioral counseling, as recommended by the Task Force, without overwhelming the practice schedules of already harried providers. Further study is needed to determine whether remotely delivered weight loss counseling is as effective as it appears to be and can delivered, at a minimum, at a lower cost than CMS pays for on-site counseling delivered by PCPs.