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Q/does brief physician counseling promote weight loss?

EVIDENCE-BASED ANSWER

A / In SOME CASES, it may. While physician counseling alone isn't more effective for weight loss than usual care (strength of recommendation [SOR]: A, larger randomized controlled trials [RCTs]), counseling (adults) as part of a multidisciplinary intervention may promote modest (2-3 kg) weight loss over 1 year (SOR: B, a single RCT).

Evidence summary

The TABLE summarizes the results of 6 RCTs that evaluated physician counseling for weight loss. The largest RCT, which included patients with elevated serum low-density lipoprotein levels (>75th percentile), randomized participants to 3 groups: physician counseling plus office support (dietary assessment tools, counseling algorithms, and in-office prompts), physician counseling alone, or usual care. (1)

Patients who received physician counseling with office support lost 2.3 kg (P<.001 vs usual care), whereas patients who received physician counseling alone lost 1.0 kg and patients who received usual care didn't lose any weight.

Other large studies show mixed results

The second largest RCT randomized participants from community health centers in Colorado to receive either physician counseling (in which physicians reviewed nutritional and physical activity goals generated by a computer in response to a survey) or usual care (patient handouts alone). (2) Although the physician-counseled group didn't lose more total weight, more people in this group had lost 2.7 kg or more at the 12-month follow-up (32% vs 19% for usual care; P=.006).

The third largest RCT assigned low-income women from primary care clinics in Louisiana to either a 6-month tailored weight loss intervention or usual care. (3) The intervention included monthly 15-minute visits with physician counseling about weight loss, fat intake, physical activity, barriers to weight loss, and weight loss maintenance. Women who received counseling lost 1.5 kg at the 9-month follow-up compared with a loss of 0.6 kg for women who received usual care. Both groups showed no net loss at the 12- and 18-month follow-up.

Counseling with follow-up leads to drop in BMI

Physician counseling in an Italian RCT included a 1-minute, patient-centered assessment of readiness for change, 2 to 5 minutes of exercise counseling by a physician for patients in active and maintenance stages, and phone or mail follow-up at 2 to 3 weeks. (4) The reported decreases in body mass index (BMI) in the counseling group would translate to 2.4 and 1.0 kg of weight loss for men and women of average height, respectively.

No significant weight loss in a pediatric study

An RCT of children brought to a pediatric clinic for well-child visits recruited children who had either a BMI in the 85th to 95th percentile or obese parents (BMI [greater than or equal to] 30 kg/[m.sup.2]). (5) Parents were randomized to intensive counseling, minimal counseling, or usual care. The intensive intervention group participated in a 10- to 15-minute motivational interview with the pediatrician, followed by 2 45-minute sessions with a dietician at months 1 and 3 of the 6-month program; the minimal intervention group only participated in the motivational interview. No significant weight loss occurred in any of the 3 study groups.

The smallest RCT compared counseling by a family medicine resident with usual care in 30 adult patients. (6) At 6 months, the counseling group had lost 0.9 kg compared with a gain of 1.3 kg in the usual care group, but follow-up at 12 months found no difference between the groups.

Recommendations

The US Preventive Services Task Force (USPSTF) says that intensive counseling (person-to-person meetings at least monthly, combined with diet, exercise, and behavioral interventions plus longer-term maintenance) can promote modest sustained weight loss and improve clinical outcomes. (7) They recommend screening adults for obesity and offering intensive counseling and behavioral interventions for obese adults.

USPSTF notes, however, that evidence is insufficient to recommend for or against low- or moderate-intensity counseling and behavioral interventions in obese or overweight adults because the trials showed mixed results, typically had small sample sizes and high dropout rates, and reported average weight change rather than frequency of response. (8)

References

(1.) Ockene IS, Hebert JR, Ockene JK, et al. Effect of physician-delivered nutrition counseling training and an office-support program on saturated fat intake, weight, and serum lipid measurements in a hyperlipidemic population: Worcester Area Trial for Counseling in Hyperlipidemia (WATCH). Arch Intern Med. 1999;159:725-731.

(2.) Christian JG, Bessen DH, Byers TE, et al. Clinic-based support to help overweight patients with type 2 diabetes increase physical activity and lose weight. Arch Intern Meal. 2008;168:141-146.

(3.) Martin PD, Dutton GR, Rhode PC, et al. Weight loss maintenance following a primary care intervention for low-income minority women. Obesity. 2008; 16:2462-2467.

(4.) Bolognesi M, Nigg CR, Massarini M, et al. Reducing obesity indicators through brief physical activity counseling (PACE) in Italian primary care settings. Ann Behav Med. 2006;31:179-185.

(5.) Schwartz RE, Hamre R, Dietz WH, et al. Office-based motivational interviewing to prevent childhood obesity:, a feasibility study. Arch Paediatr Adolesc Med. 2007;161:495-501.

(6.) Cohen MD, D'Amico FJ, Merenstein JH. Weight reduction in obese hypertensive patients. Faro Med. 1991;23:25-28.

(7.) Mctigue KM, Harris R, Hemphill B, et al. Screening and interventions for obesity in adults: summary of the evidence for the US Preventive Services Task Force. Ann Intern Med. 2003; 139:933-949.

(8.) United States Preventive Services Task Force. Screening for obesity in adults. December 2003. Available at: http://www. uspreventiveservicestaskforce.org/uspstf/uspsobes.htm. Accessed August 27, 2010.

Jessica Cabodi, MD; Gary Kelsberg, MD

Valley Family Medicine

Residency, Renton, Wash

Sarah Safranek, MLIS

University of Washington

Health Sciences Library, Seattle

ASSISTANT EDITOR

Jon O. Neher, MD

Valley Family Medicine

Residency, Renton, Wash
TABLE
The effectiveness of weight loss counseling by physicians:
What the RCTs reveal

Number and              Duration of
characteristics         intervention   Study design
of patients

1162 adults from        12 mo          3 arms:
internal medicine
clinics (mean BMI=29                   1. Physician counseling
kg/[m.sup.2]) (1)                      plus office support

                                       2. Physician counseling
                                       alone

                                       3. Usual care

310 adult Hispanic      12 mo          Physician counseling
patients with type 2                   vs usual care
diabetes (mean BMI=35
kg/[m.sup.2]) (2)

144 adult African       6 mo           Physician counseling
American women (mean                   vs usual care
BMI=39 kg/[m.sup.2])
(3)

96 Italian adults       5-6 mo         Physician counseling
(mean BMI=25 kg/                       vs usual care
[m.sup.2]) (4)

91 children (3-7        6 mo           3 arms:
years of age) either
overweight or with                     1. Intensive physician
obese parents (5)                      counseling

                                       2. Minimal physician
                                       counseling

                                       3. Usual care

30 Israeli adults       6 mo           Resident physician
with hypertension                      counseling vs usual care
(mean BMI=34 kg/
[m.sup.2]) (6)


Number and              Weight change
characteristics
of patients

1162 adults from
internal medicine       1. -2.3 kg; P<.001
clinics (mean BMI=29    vs usual care
kg/[m.sup.2]) (1)
                        2. -1.0 kg (P value not
                        reported) vs usual
                        care

                        3. 0 kg; reference
                        standard

310 adult Hispanic      -0.1 kg vs +0.6 kg gain;
patients with type 2    P=.23
diabetes (mean BMI=35
kg/[m.sup.2]) (2)

144 adult African       -1.5 kg vs -0.6 kg
American women (mean    at 9 mo; P.01
BMI=39 kg/[m.sup.2])
(3)                     0 kg net loss in both
                        groups at 12- and
                        18-month follow-up

96 Italian adults       Men:
(mean BMI=25 kg/
[m.sup.2]) (4)          BMI decrease from 30.3
                        to 29.5 kg/[m.sup.2] VS
                        increase from 31.9 to
                        32.4 kg/[m.sup.2]; P<.05

                        Women:

                        BMI decrease from 30.6
                        to 30.2 kg/[m.sup.2] vs
                        increase from 30.7 to
                        31.0 kg/[m.sup.2]; P<.05

91 children (3-7        No significant weight
years of age) either    loss in any group
overweight or with
obese parents (5)

30 Israeli adults       -0.9 kg vs +1.3 kg at 6
with hypertension       mo; P value not given
(mean BMI=34 kg/
[m.sup.2]) (6)          No difference between
                        groups at 12-mo
                        follow-up
BMI, body mass index.
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Title Annotation:CLINICAL INQUIRIES: Evidence-based answers from the Family Physicians Inquiries Network
Author:Cabodi, Jessica; Kelsberg, Gary; Safranek, Sarah
Publication:Journal of Family Practice
Geographic Code:1USA
Date:Sep 1, 2011
Words:1335
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