Boston, MA—Intensive behavioral interventions can be successful in helping overweight patients achieve modest weight loss, said Lawrence J. Appel, MD, MPH, Director, Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, MD, at the 2012 Cardiometabolic Health Congress.
Even small amounts of weight loss have beneficial effects on cardiovascular (CV) risk, including reducing the risk of developing diabetes or hypertension and improving the lipid profile of patients with dyslipidemia.
Components of Behavioral Intervention
The patient’s readiness to participate in behaviorial intervention to effect weight loss should be assessed. Candidates for weight-loss intervention are those who are in the contemplation, preparation, and action stages of behaviorial change. For these patients, a weight-loss goal of 5% through behavioral intervention is achievable, said Dr Appel. The intervention should incorporate:
- Reduced caloric intake: consumption of a health dietary pattern based on the DASH (Dietary Approaches to Stop Hypertension) diet
- Exercise for at least 180 minutes weekly
- Counseling patients to monitor their weight, caloric intake, and duration of exercise regularly.
For the intervention to have the highest chance of success, realistic goals for target weight must be set. “Aim for a healthier weight, not ideal weight,” advised Dr Appel. “Promote slow, incremental progress to the goal.” The initial 6-month weight-loss goal should be 1 to 2 lb weekly until a weight loss of 5% to 10% is achieved; the subsequent goal should be maintenance of the weight loss.
A loss of 1 to 2 lb weekly is achievable and corresponds to a caloric deficit of approximately 500 to 1000 kcal daily. This rate of weight loss is safe and does not require close monitoring, with the exception of patients with diabetes. In contrast, rapid weight loss can have complications, Dr Appel pointed out.
Weight Loss in Clinical Studies
In studies of behavioral weight-loss intervention, patients who undertake lifestyle intervention typically experience a “check mark” pattern of weight loss, which is weight loss followed by regain, although occasionally the initial weight loss is sustained. Patients in control groups in such studies have a variable pattern of weight change: some will gain weight, others will lose weight, or some will have no change in body weight.
“Mean weight loss [in active intervention groups] of 3% to 7% of initial body weight is typical, but interindividual variability is high,” said Dr Appel.
A trial called Power-Up, which was carried out at the University of Pennsylvania, demonstrated that primary care physicians working in their own practices can induce clinically significant weight loss in their obese patients, and that medical assistants could contribute to weight management efforts. The 2-year trial compared 3 interventions in 390 obese people: usual care (quarterly visits to a primary care physician), brief lifestyle counseling, or enhanced lifestyle counseling.
The patients in the brief lifestyle counseling group had quarterly visits to their primary care physician and brief visits with a medical assistant approximately every month. The enhanced lifestyle counseling group had the same brief lifestyle counseling with the addition of the use of meal replacements or weight-loss medications.
At 2 years, the usual-care group lost a mean of 1.7 kg, the brief lifestyle counseling group lost a mean of 2.9 kg, and the enhanced lifestyle counseling group lost a mean of 4.6 kg (significantly more than the usual-care group; P = .003). At month 12, twice as many patients in the enhanced lifestyle counseling group lost at least 5% of their body weight than patients in the usual-care group (47.3% vs 24.6%, respectively; P <.001), an advantage that was lessened but still significant at month 24 (34.9% vs 21.5%, respectively; P = .027). The percentage that lost at least 5% of body weight was also significantly greater at months 12 and 24 in the enhanced lifestyle counseling group versus the brief lifestyle counseling group.
The Centers for Medicare & Medicaid Services now covers intensive behavioral weight-loss counseling, noted Dr Appel. In Johns Hopkins’ POWER trial, weight loss at 24 months was nearly equal between a group assigned to remote support versus in-person delivery of weight-loss interventions. Approximately 40% of both groups lost at least 5% of body weight, and approximately 20% in each group lost at least 10% compared with 19% and 9%, respectively, of a control group.