Behavioral Treatment of Obesity in Patients Encountered in Primary Care Settings

The incidence of obesity in the United States and worldwide has increased substantially in the last few decades and is a subject of increasing professional attention. The US Preventive Services Task Force has recommended that primary care providers screen all adults for obesity and that affected individuals should be offered intensive behavioral counseling (intervention), either by providing such treatment themselves or by referral. The Centers for Medicare & Medicaid Services (CMS) in 2011 approved provision of intensive behavioral weight loss counseling for obese patients seen in primary care. The recommended behavioral intervention was approximately 14 face-to-face, 10- to 15-minute sessions over 6 months when delivered by primary care physicians and other CMS-defined primary care practitioners. The aim of this systematic review was to summarize the results of randomized controlled trials involving overweight and obese patients who received behavioral counseling delivered by CMS-defined primary care practitioners, working alone or with trained interventionists (eg, medical assistants, registered dietitians), or by trained interventionists working independently. A search of PubMed, CINAHL, and EMBASE was conducted from 1980 through June 30, 2014, to identify randomized controlled trials involving overweight and obese patients recruited from a primary care setting that met the following criteria: behavioral counseling (ie, diet, exercise, and behavioral therapy) for at least 3 months, with at least 6 months of postrandomization follow-up; a minimum of 15 participants per treatment group; objectively measured weights; and use of a comparator, an intention-to-treat analysis, and attrition of less than 30% at 1 year or less than 40% at longer follow-up. Among 3304 abstracts identified in the initial review, 12 trials (involving 3893 participants) met criteria for inclusion-exclusion and prespecified quality ratings. No trials were found in which delivery of counseling by primary care practitioners followed the CMS obesity guidelines. In the intervention group, mean 6-month weight changes from baseline ranged from a loss of 0.3 to 6.6 kg, whereas in the control group, mean change ranged from a gain of 0.9 kg to a loss of 2.0 kg. There was a similar decline in weight loss in both groups with longer follow-up (12–24 months). Smaller weight losses were achieved with interventions that did not provide all 3 components prescribed in the obesity guidelines (reduced energy intake, increased physical activity, and traditional behavioral therapy). Behavioral health counseling delivered in person or with the telephone by a range of trained interventionists working with or independently of primary care physicians provided clinically meaningful weight loss in obese or overweight persons seen in a primary care setting. These findings show that intensive behavioral intervention following recommended obesity guidelines of calorie restriction, exercise, and behavioral counseling can induce clinically meaningful weight loss. There is little or no evidence that primary care practitioners provide such care. The data suggest that physician referral to a range of trained interventionists who deliver counseling in person or by telephone should be considered for treating overweight or obese patients encountered in primary care setting.