Extensive gap exists between primary care practice and obesity care

Jan 27 2010

Using combined and intensive treatments and restructuring care to treat obesity like other chronic diseases may help primary care clinicians and patients better address the condition, according to a commentary and three articles published in the January 25 issue of Archives of Internal Medicine, one of the JAMA/Archives journals.

Data suggest an extensive gap exists between recommended obesity care and current practice by primary care clinicians, notes Robert F. Kushner, M.D., of Northwestern University Feinberg School of Medicine, Chicago, in the commentary. "The reasons for the gap are complex owing to multiple physician, patient and medical system factors," he writes. "Cited barriers include a lack of reimbursement, limited time during office visits, lack of training in counseling, competing demands, low confidence in the ability to treat and change patient behaviors, limited resources, the perception that patients are not motivated and a paucity of proven and effective interventions to treat obesity."

"In this issue of the Archives, three articles on weight loss for overweight or obese patients have potential implications for primary care practice," Dr. Kushner writes. The findings, outlined below, provide information on effective interventions for obesity and its complications in primary care settings.
(Arch Intern Med. 2010;170[2]:121-123. Available pre-embargo to the media at www.jamamedia.org.)

Blood Pressure-Lowering Diet Appears More Effective When Combined With Other Interventions

Combining an anti-hypertension diet with exercise and weight loss counseling may result in increased reduction in high blood pressure along with other benefits. James A. Blumenthal, Ph.D., of Duke University Medical Center, Durham, N.C., and colleagues studied 144 overweight or obese patients with high blood pressure. For four months, 46 were assigned to follow the Dietary Approaches to Stop Hypertension (DASH) diet; 49 followed the diet and added supervised exercise and cognitive-behavioral weight loss therapy; and 49 ate their usual diet.

Blood pressure as measured in the clinic decreased by 16.1/9.9 millimeters of mercury among those in the DASH plus weight management group, 11.2/7.5 millimeters of mercury among those in the DASH alone group and 3.4/3.8 millimeters of mercury in those following their normal diet. Other measures of blood vessel and heart function—including mass of the left ventricle—were also most improved in patients assigned to DASH plus weight management.

"The present findings suggest that the DASH diet, particularly when augmented by exercise and weight loss, can offer considerable benefit to patients with high blood pressure, not only through reductions in blood pressure but through favorable modification of biomarkers of disease risk," the authors conclude.

Low-Carb Diet May Lead to Similar Benefits as Weight Loss Medication Combined With a Low-Fat Diet

A low-carbohydrate diet appears to be associated with substantial weight loss similar to that produced by a combination of the weight-loss drug orlistat and a low-fat diet, but may be more effective in reducing blood pressure. William S. Yancy Jr., M.D., M.H.S., and colleagues at the Department of Veterans Affairs Medical Center and Duke University Medical Center, Durham, N.C., examined body weight, metabolic and adverse effects in obese or overweight outpatients ages 18 to 70 who were randomly assigned to one therapy or the other for 48 weeks.

Of the participants, 57 in the low-carb diet group and 65 in the orlistat and low-fat diet group completed the study. Weight loss was similar for both groups (an average of 8.5 percent to 9.5 percent of body weight), but the low-carb diet resulted in greater reductions to systolic (top number) and diastolic (bottom number) blood pressures. High-density lipoprotein cholesterol and triglyceride levels improved similarly in both groups.

"In conclusion, the low-carbohydrate ketogenic diet and the orlistat plus low-fat diet were equally effective for weight loss and several cardiovascular disease risk factors, although the low-carbohydrate diet was more effective for lowering blood pressure," the authors conclude. "Efforts should be made to incorporate similarly intensive weight loss programs into medical practice."

Non-Surgical Program Helps Some Extremely Obese Adults Lose Weight

About one-third of adults with extreme obesity benefited after two years of an intensive medical management program conducted by primary care clinicians. Donna H. Ryan, M.D., of Pennington Biomedical Research Center, Baton Rouge, La., and colleagues trained seven primary care physicians and one research clinic in obesity management.

A group of 200 adults with extreme obesity (body mass index of higher than 40) were randomly assigned to participate in the intervention, which involved a short-term liquid diet, group behavioral counseling, a longer-term maintenance diet and one of several medications. After two years, 51 percent remained on the program, 31 percent lost 5 percent or more of their body weight and 7 percent lost 20 percent or more. Comparatively, in the group of 190 control participants assigned to follow their usual diet, 46 percent remained in the study, 9 percent lost 5 percent or more of their body weight and 1 percent lost 20 percent or more after two years.

"Primary care practices can initiate effective medical management for extreme obesity; future efforts must target improving retention and weight loss maintenance," the authors conclude.

Source: Archives of Internal Medicine