Nearly a decade ago, with the deadly implications of America's obesity epidemic first sinking in, medical guidelines recommended that providers screen all adult patients and offer weight-loss help to those that need it. But with few proven techniques for family physicians to use, no training, and no insurance reimbursement, the guidance is often ignored.
Now two new studies - one from the University of Pennsylvania, the other from Johns Hopkins - offer some of the first evidence of success with weight-loss programs that the authors said would be relatively easy for primary care providers to put into practice.
Neither is a magic pill. In the Penn study, adult patients met quarterly with their regular doctor, monthly with a coach, and took a weight-loss drug or commercial meal-replacement product. In the Hopkins study, regular doctor visits were supported by an interactive web site plus coaching in person or by phone, Internet and email.
In both studies, patients had lost an average of more than 10 pounds after two years. That modest amount, experts said, can be enough to prevent the development of serious health conditions such as diabetes.
And by relying heavily on lower-paid "coaches" with limited training, both programs likely cost less than a doctor's time would. A big unanswered question, however, is whether insurance companies would pay for any of it.
Although some commercial programs like Weight Watchers are effective, only the most highly motivated people sign up on their own.
"When patients are told by their doctor that they need to lose weight it is a much more important source of authority," said Morgan Downey, a longtime healthcare advocate and publisher of downeyobesityreport.com. Plus, he said, the doctor may also be treating various conditions, from asthma to back pain, that are exacerbated by obesity. "So the message there is that losing weight is not just a good virtue in itself but is related to making better the condition that we are treating today," he said.
Even if a physician makes a referral to a commercial program, many patients never show up, said Thomas Wadden, lead author of the Penn study.
His program was located in physicians' own offices. At the end of an appointment the doctor can say, "I want you to walk down the hall and see our medical assistant," said Wadden, "and I might capture you and get you started right then and there."
Wadden, director of the Center for Weight and Eating Disorders at Penn's Perelman School of Medicine, presented the findings at an American Heart Association conference in Orlando, Fla., on Monday afternoon; the Hopkins research is being presented on Tuesday. Both were simultaneously published online in the New England Journal of Medicine.
Previous studies have shown that 50 percent of primary care physicians don't even raise the issue of weight loss with patients who clearly would benefit.
"Up until this point if you were an obese patient and went to your doctor there was no proven strategy for you to lose weight," said Lawrence J. Appel, a primary care internist in Baltimore. Appel said he would discuss diet with his patients, help them set goals and sometimes encourage them to enroll in independent programs, with mixed results.
"The office environment is incredibly hectic," he said. He thought weekly contact as well as additional outside support might make a difference.
To test that idea, Appel, who is also a professor of medicine at Hopkins and lead author of that study, randomly divided 415 obese patients from six primary care practices into three groups.
One received little guidance other than a standard booklet and whatever meetings with their physicians they would have normally scheduled over the two years.
A second group also had access to an interactive web site that allowed them to track diet and exercise. Their doctors encouraged them to participate in 20-minute sessions with coaches - weekly in the beginning, then monthly, and then every other month - by email or phone. They also got feedback via weekly automated emails.
Members of a third group got the web site, automated feedback, and coaching - but for them the counseling was face to face, in 90-minute group sessions plus optional individual sessions. It also was more frequent - at least twice a month for two years.
To the researchers' surprise, the remotely coached group did just as well as the in-person group - a loss of 10 pounds vs. 11 pounds, an insignificant difference. (The group that got minimal help lost 2 pounds.)
Although the study did not estimate costs, Appel noted that remote coaching could be done from anywhere, even "around the world."
The Penn study also enrolled about 400 patients with body mass indexes over 30 - the definition of obese - from six primary care practices for two years and assigned them to three groups.
One group got nutrition handouts and pedometers, and had quarterly visits with their doctors, who spent five to seven minutes each time reviewing their weight and discussing the handouts.
A second group also met monthly with a medical assistant in the office who had six to eight hours of training as a coach and worked with them to track food and exercise.
A third group did all of the above and also had to choose either of two possible "enhancements": One was a meal replacement bar or shake such as Slim-Fast (for two daily meals plus a snack during the first four months and one meal and a snack for the last 20 months). The other was a weight-loss drug (orlistat or sibutramine, although the latter was removed from the market partway through the study and those patients switched over).
This study's surprise was that the patients who got the least help still dropped an average of nearly 4 pounds. Just the minimal guidance was "more care than usual," said Wadden, a professor of psychology, and "they may have been motivated to impress their doctor."
The coached group lost an average of 6 pounds. The coach-plus meal replacement or drug group lost 10 pounds, or an average of nearly 5 percent of their initial weight, the only amount that was considered clinically meaningful.
"What really sets these two studies apart is that it extends the reach of treatment" beyond specialized clinics, said Gary D. Foster, director of Temple University's Center for Obesity Research and Education, who was not involved with either one. Primary care doctors are used to dealing with diabetes and high cholesterol, he said, but "you can't write a script for obesity." The new results, Foster added, give them a place to start.
Still, he and others said, the scientific findings do not address a big bureaucratic barrier: Insurance companies typically pay little or nothing for doctors to treat obesity with counseling or drugs, and have only recently added some coverage for weight-loss surgery.
There are some signs of change. Medicare for the first time has proposed covering up to a year of behavioral counseling in primary care settings. The final rule, due in two weeks, is unlikely to allow payments for coaching online or by medical assistants without advanced degrees.
"I think it is a step in the right direction," said Karen Grothe, a psychologist who treats obese patients at the Mayo Clinic in Rochester, Minn., and had cited earlier research by Wadden in a public comment that urged the government to adopt a more expansive rule.