Finding weight loss strategies that work in primary care

Transcription

1 Finding weight loss strategies that work in primary care Article: Wilson C. Obesity: Finding weight loss strategies that work in primary care. Nat Rev Endocrinol. 2013;9(3):126. Review: In this Research Highlights article, Carol Wilson, PhD, associate editor of Nature Reviews Endocrinology, comments on the results of 2 recent randomized, controlled trials that evaluated different weight loss strategies and their potential impact on primary care. 1 Dr Wilson first discusses the landmark Diabetes Prevention Program (DPP) study, which demonstrated the efficacy of lifestyle modifications for weight loss and reducing the risk of type 2 diabetes mellitus (T2DM). 2 The original DPP study, funded by the National Institutes of Health and supported by the Centers for Disease Control and Prevention, 2 included a total of 3234 nondiabetic participants from 27 clinical centers across the United States who were randomly assigned to 1 of 3 treatment groups: lifestyle intervention (intensive one-on-one intervention with a trained interventionist to address nutrition, exercise, and behavior modification); standard care (information on diet and exercise, but no intensive lifestyle intervention plus 850 mg of the glycemic control drug metformin twice daily); or standard care plus a placebo. All study participants were overweight and had impaired glucose tolerance (IGT), a well-recognized risk factor for developing T2DM. Each group s target goal was 5%-7% reduction in baseline body weight. After an average follow-up of 2.8 years, lifestyle intervention reduced the risk of progression to diabetes by 58% compared with 31% for patients who took metformin. 2 The incidence of diabetes was 11.0, 7.8, and 4.8 cases per 100 person-years in the placebo, metformin, and lifestyle groups, respectively. 2 Since the DPP results were published, lifestyle intervention has been incorporated into clinical guidelines for weight management and disease prevention. 3 Most recently, Ma and colleagues (Palo Alto Medical Foundation Research Institute, California) 3 set out to translate the findings from the DPP study to the primary care setting. Their study, the Evaluation of Lifestyle Interventions to Treat Elevated Cardiometabolic Risk in Primary Care (E- LITE) trial, was a randomized, controlled clinical trial in adults with overweight or obesity and prediabetes and/or metabolic syndrome enrolled from one primary care clinic. Participants were randomized to 1 of 3 arms: a coach-led, DPP-based lifestyle intervention (n=79); a self-directed, DVD-based lifestyle intervention (n=81); or usual care without information about weight loss or weight loss goals (n=81). The percentages of participants who achieved the 7% DPP-based weight-loss goal were assessed. During the 3-month intensive intervention phase of the study, the DPP-based behavioral weight-loss curriculum was delivered via either coach-led small groups or home-based DVD. 3 This was followed by a 12-month maintenance phase, in which lifestyle coaching and support were delivered remotely via an Internet resource (American Heart

2 Association Heart360 Web site for weight and physical activity goal setting and self-monitoring) and communications. After 15 months, the mean change in body mass index (BMI) from baseline was 2.2 in the coach-led group and 1.6 in the self-directed group versus 0.9 in the usual care group (P<0.001 and P=0.02, for the two DPP intervention arms, respectively). The predefined 7% DPP-based weight loss goal was met by 37% in the coach-led group (P=0.003), 36% in the self-directed group (P=0.004), and 14% in the usual care group. In addition, both interventions achieved greater net improvements in waist circumference and fasting plasma glucose level versus placebo. In her commentary, Dr Wilson indicates that the E-LITE study provides two empirically supported programs that can be readily adopted into routine [primary care] practice. 1,3 Figure 1 illustrates similar findings for the 5% and 10% weight-loss goal cut-points. Figure 1. Categorical weight loss at 6 and 15 months in the intention-to-treat population. Weight loss (A) less than or equal to baseline weight, (B) greater than or equal to 5% of baseline weight, (C) greater than or equal to 7% of baseline weight, and (D) greater than or equal to 10% of baseline weight. [Reprinted with permission from Ma J, Yank V, Xiao L, et al. Translating the Diabetes Prevention Program lifestyle intervention for weight loss into primary care: a randomized trial. JAMA Intern Med. 2013;173(2): ]

3 The second study in Dr Wilson s commentary, published by Spring et al (Department of Preventive Medicine, Northwestern University, Chicago, Illinois), evaluated a mobile app-based weight loss strategy with potential for use in the primary care setting. 4 This 12-month study enrolled 69 adults with a BMI >25 and 40 from a Midwestern Veterans Affairs (VA) medical center outpatient clinic. Participants first completed a technology fluency assessment and received training on the use of a personal digital assistant (PDA) to record food intake, weight, and physical activity. They were then randomly assigned to either standard care or standard care supported by a PDA (+mobile group). Standard care consisted of the MOVE! group weight loss program, which is offered at all VA medical centers, and includes biweekly weight-loss sessions led by dietitians, psychologists, or physicians. 5 In addition to standard care, the +mobile group members were provided with PDAs, which they used to upload their daily diet and physical activity; they also received minute coaching calls every 2 weeks for 6 months. An intent-to-treat analysis showed that participants assigned to the +mobile group lost a mean of 3.9 kg more weight (3.1% more weight loss relative to the control group) than those in the standard group at each post-baseline time point; there was no evidence that treatment effect varied across time. Figure 2 shows weight loss measured during specific time points. Compared with the standard group, the +mobile group had a significantly greater likelihood of achieving 5% weight loss from baseline at all time points: 36.7% for +mobile versus 0% for standard at 3 months; 41.4% versus 10.7% at 6 months; 33.3% versus 10.3% at 9 months; and 29.6% versus 14.8% at 12 months. 4 Participants in the +mobile group who were more adherent to the MOVE! program (evidenced by attending 80% of treatment sessions) lost significantly more weight than less adherent +mobile-group participants and either adherent or non-adherent standard group participants. Figure 2. Weight loss plotted over time for the connective mobile technology (+mobile) and standard groups. Weight loss was significantly greater for the +mobile group at 3, 6, and 9 months. [Reprinted with permission from Spring B, Duncan JM, Janke A, et al. Integrating technology into standard weight loss treatment: a randomized controlled trial. JAMA Intern Med. 2013;173(2): ]

4 These findings indicate that mobile technology is a scalable, cost-effective means to augment the effectiveness of physician-directed weight loss treatment. 4 Data from other studies support the idea that intensive lifestyle interventions may not need to be performed in person to achieve meaningful weight loss. For example, Appel et al 6 demonstrated that telephone- and Internet-based treatment produced weight loss comparable to an in-person intervention among patients referred from primary care practices. Dr Wilson agrees with Spring et al 4 in that technology offers a very effective way to deliver components of weight loss treatment. 1 In conclusion, the randomized trials by Ma et al 3 and Spring et al 4 highlight the promise of effective weight loss strategies that can be readily adapted for the primary-care setting. Mobile technology offers a new way for clinicians and other health professionals to provide personalized components of behavioral weight loss treatment (ie, self-monitoring, goal setting, lifestyle counseling, and in-person sessions) at reduced cost and participant burden, thereby easing the strain on primary-care systems. 4

5 References 1. Wilson C. Obesity: finding weight loss strategies that work in primary care. Nat Rev Endocrinol. 2013;9(3): Knowler WC, Barrett-Connor E, Sowler SE, et al; for the Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. 2002;346(6): Ma J, Yank V, Xiao L, et al. Translating the Diabetes Prevention Program lifestyle intervention for weight loss into primary care: a randomized trial. JAMA Intern Med. 2013;173(2): Spring B, Duncan JM, Janke A, et al. Integrating technology into standard weight loss treatment: a randomized controlled trial. JAMA Intern Med. 2013;173(2): Kinsinger LS, Jones KR, Kahwati L, et al. Design and dissemination of the MOVE! weightmanagement program for veterans. Prev Chronic Dis. 2009;6(3):A Appel LJ, Clark JM, Yeh HC, et al. Comparative effectiveness of weight-loss interventions in clinical practice. N Engl J Med. 2011;365(21):