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Implementation of a Primary Care Physician Network Obesity Management Program Susan Bowerman, Mindy Bellman, Pamela Saltsman, Denise Garvey, Kevin Pimstone, Samuel Skootsky, He-Jing Wang, Robert Elashoff, and David Heber

Abstract BOWERMAN, SUSAN, MINDY BELLMAN, PAMELA SALTSMAN, DENISE GARVEY, KEVIN PIMSTONE, SAMUEL SKOOTSKY, HE-JING WANG, ROBERT ELASHOFF, AND DAVID HEBER. Implementation of a primary care physician network obesity management program. Obes Res. 2001;9:321S–325S. Most primary care physicians do not treat obesity, citing lack of time, resources, insurance reimbursement, and knowledge of effective interventions as significant barriers. To address this need, a 10-minute intervention delivered by the primary care physician was coupled with individual dietary counseling sessions delivered by a registered dietitian via telephone with an automated calling system (HouseCalls, Mobile, AL). Patients were seen for follow-up by their physician at weeks 4, 12, 24, 36 and 52. A total of 252 patients (202 women and 50 men) were referred by 18 primary care physicians to the program. The comorbid conditions reported for all patients at baseline included low back pain, 29% (n ⫽ 72); hypertension, 45% (n ⫽ 113); hypercholesterolemia, 41% (n ⫽ 104); type 2 diabetes, 10% (n ⫽ 26); and sleep apnea, 5% (n ⫽ 12). When offered a choice of meal plans based on foods or meal replacements, two-thirds of patients (n ⫽ 166) chose to use meal replacements (Ultra Slim-Fast; Slim-Fast Foods Co., West Palm Beach, FL) at least once daily. Baseline weights of subjects averaged 200 ⫾ 46 lb for women (n ⫽ 202) and 237 ⫾ 45 lb for men (n ⫽ 50). Patients completing 6 months in the program lost an average of 19.0 ⫾ 4.0 lb for women (n ⫽ 94) and 15.5 ⫾ 8.2 lb for men (n ⫽ 26). Physicians reported a high degree of satisfaction with the program, suggesting that a brief, effective physician-directed program with nutritionist support by telephone can be implemented in a busy primary care office.

University of California, Los Angeles, Center for Human Nutrition, Los Angeles, California. Address correspondence to Dr. Susan Bowerman, University of California, Los Angeles Center for Human Nutrition, Warren Hall Room 12-217, 900 Veteran Avenue, Los Angeles, CA 90095-1742. E-mail: [email protected] Copyright © 2001 NAASO

Key words: primary care, meal replacement, physiciandirected diet, weight loss, practical guidelines

Introduction With the incidence of overweight and obesity among adults in the United States at an all-time high and continuing to rise, the number of patients seeking advice for weight management in the primary care setting is likely to parallel this trend. Most adults in primary care settings are overweight or obese, and two-thirds of patients with weight problems have obesity-related conditions (1). Many primary care physicians are reluctant to treat overweight and obese patients, citing lack of time, patient noncompliance, inadequate teaching materials, lack of counseling training, inadequate reimbursement, and low physician confidence as barriers to treatment (2– 8). Among those who do address dietary issues with their patients, the time spent discussing weight management has been reported to be 5 minutes or less (2). However, primary care physicians reach most segments of the population, and their expertise is highly regarded by their patients (9), placing them in a unique position to provide nutrition information. Traditionally, physicians have referred patients out of the office for dietary counseling, although there are those who express interest in counseling their patients for weight management. To address some of the more important issues of time constraints, lack of physician education, lack of patient-teaching materials, and perceived lack of self-efficacy, we developed a new model for a primary care office-based weight management program that positions the physician as the agent of change and that provides for telephonic dietitian follow-up consultation. In a 1-day chart review within the University of California, Los Angeles Healthcare Network, comprising 20 medical practices throughout Southern California, 33% of patients visiting the clinics had a body mass index (BMI) between 25 and 29.9 kg/m2, 23% had a BMI between 30 and 39.9 kg/m2, and 4% had a BMI of 40 kg/m2 or higher. These findings are similar to other reports (10) and are OBESITY RESEARCH Vol. 9 Suppl. 4 November 2001

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Obesity Treatment in a Primary Care Network, Bowerman et al.

higher than the incidences reported in population-based surveys (11). Because the network had no specific program for weight management within the primary care setting, we approached physicians within the network to identify those with a particular interest in weight management. A workshop was held to discuss current assessment and treatment of overweight and obesity and to determine from interested physicians how to structure the most effective program within the primary care setting. Program materials were then developed with the goal of providing primary care practitioners tools for a brief, direct intervention with their overweight and obese patients.

Table 1. Obesity treatment plan Time line Week 1

Research Methods and Procedures Implementation guidelines developed to describe the principles of the 1-year program include the following: the role of the physician as an agent of change, determination of BMI and body composition in patient assessment, the use of meal replacements and portion-controlled meals for calorie control, the identification of high-calorie trigger foods in the diet and the management of their intake, reinforcement of the role of exercise in weight management, and guidelines for the use of pharmacotherapy, where indicated. The program is designed to be 12 months long and is outlined with recommended appointment intervals with the physician and interventions at each visit (Table 1). The plan calls for telephone follow-up consultation with a registered dietitian at weekly intervals for the first 12 weeks and monthly for the remaining 9 months. A patient–physician Guide to Healthy Weight Loss Worksheet was developed for physicians and patients to complete. Information gathered from the patient portion of the worksheet allows the physician to assess the patient’s readiness to change, and the portion of the worksheet completed by the physician promotes his or her role as a partner in treatment. Handouts for patient use were also developed. Meal plans for 1200- and 1500-calorie diets, incorporating the use of meal replacements and portion-controlled meals, were designed for simplicity of explanation and implementation. Supporting handouts, which provide caloric values for fruits, vegetables, and starchy vegetables in the meal plan; information on the use of meal replacements and the avoidance of trigger foods; and the value of regular exercise complete the patient education materials packet. A patient enrollment form was also developed, which was designed to collect patient information regarding weight, height, BMI, body fat percentage and target weight, comorbid conditions, calorie level prescribed, and prescription medications given, if any. On the same form, the patient signs and indicates the days and times that they prefer to be called by the dietitian. Once all of the materials were developed, interested physicians were visited personally for an introduction to the program. A notebook containing the implementation guidelines and handout masters were provided to each physician, 322S

OBESITY RESEARCH Vol. 9 Suppl. 4 November 2001

Weeks 1 to 12 Week 4 Week 12

Week 24

Weeks 12 to 52 Week 36 (9 month) Week 52 (12 month)

Type of intervention Initial doctor appointment ● Baseline labs for comorbidities (diabetes mellitus, hyperlipidemia)* ● Weight, height, body mass index ● Bioelectrical impedance analysis (BIA) ● Patients return for blood pressure and weight check at week 2—if on pharmacotherapy) Diet counselor calls weekly during weeks 1 to 12 Follow-up doctor’s appointment Repeat laboratory assessment of comorbidities Physician phone follow-up for laboratory interpretation as needed. Follow-up with doctor, repeat BIA Assess weight loss progress If patient not making progress, consider referral to other resources Monthly diet counseling by telephone as needed Follow-up doctor’s appointment Follow-up doctor’s appointment Repeat BIA Repeat laboratory assessment

* Recommended laboratory assessment: comprehensive panel, lipid panel.

and guidelines for patient enrollment were reviewed. Each physician office was provided a bioelectrical impedance analyzer (BioDynamics, Inc., Seattle, WA) and physicians and staff members were trained in use of the equipment and interpretation of data collected from the analysis. Once physicians offered the program to the patient, enrollment forms were faxed to a registered dietitian located offsite at our center, and enrollment was then complete. An automated telephone calling system (HouseCalls, Mobile, AL) was installed to allow the telephone counselor to monitor the calling schedule and to facilitate patient calling through


Table 2. Baseline weights, body mass index, and body fat percentage

Weight (kg) Body mass index (kg/m2) Body fat (%)

Men (n ⴝ 50)

Women (n ⴝ 202)

90.7 ⫾ 21.1 34 ⫾ 6 31.9 ⫾ 4.9

107.5 ⫾ 20.6 33 ⫾ 7 37.9 ⫾ 5.3

automated dialing. The system also has the capability to record messages in the counselor’s own voice, which can then be sent by automatic dialing to all enrolled patients. Although all patients are speaking directly with the dietitian, the recorded messages have been used as a retention strategy, such as sending patients encouraging messages over the winter holiday season, and can be used for sending appointment reminders, birthday greetings, or research news. Following the guidelines, the registered dietitian telephoned each patient enrolled in the program once a week for the first 12 weeks and monthly for the remaining 9 months according to the days and times specified by the patient on the enrollment form. The telephone counselor provides support, guidance, and encouragement to the patients and answers dietary questions. The counselor also gathers information about the patient’s weight loss, diet, medication and exercise compliance, and use of meal replacements. Physicians receive a monthly faxed report from the dietitian summarizing the results of all telephone contacts with the enrolled patients. A separate form is prepared for each patient so that the information can be easily placed in the patient’s chart.

Results To date, a total of 252 patients (202 women and 50 men) have been referred to the program by 18 primary care physicians in the University of California, Los Angeles Healthcare Network. Baseline weights of subjects averaged 200 ⫾ 46.5 lb (90.7 ⫾ 21.1 kg) for women (n ⫽ 202) and 237 ⫾ 45.4 lb (107.5 ⫾ 20.6 kg) for men (n ⫽ 50). BMI at baseline was 34 ⫾ 6 kg/m2 and 33 ⫾ 7 kg/m2 for men and women, respectively. Men had a mean body fat percentage, as measured by bioelectrical impedance, of 31.9 ⫾ 4.9% at baseline, and women had baseline body fat percentage averaging 37. 9 ⫾ 5.3% (Table 2). The comorbid conditions reported for all subjects at baseline included low back pain, 29% (n ⫽ 72); hypertension, 45% (n ⫽ 113); hypercholesterolemia, 41% (n ⫽ 104); type 2 diabetes, 10% (n ⫽ 26); and sleep apnea, 5% (n ⫽ 12; Table 3). Women completing 3 months in the program (n ⫽ 123) lost an average of 9.2 lb (4.2 kg) and men (n ⫽ 33) lost

Table 3. Comorbid conditions at baseline (N ⫽ 252)

Hypertension Hypercholesterolemia Musculoskeletal pain Type 2 diabetes Sleep apnea

Number affected

Percentage affected

113 104 72 26 12

45 41 29 10 5

an average of 6.0 lb (2.7 kg). For those who completed 6 months, weight loss continued, with women (n ⫽ 94) losing an average of 19 lb (8.6 kg), and men (n ⫽ 26) losing an average of 15.5 lb (7.0 kg) from baseline weight (Table 4). Physicians participating in the program were surveyed after 1 year and reported a high degree of satisfaction with the program’s use within a busy practice setting. In particular, all physicians surveyed agreed that the bioelectrical impedance analysis instrument had been a valuable tool in patient assessment. Ninety percent of those responding to the survey believed that the program had benefited their practices and that they were better able to treat their patients because of the training and support they received through the program.

Discussion Obese patients are generally well-informed about diet and weight issues and do perceive the health risks associated with overweight (12). Furthermore, these individuals are in a good position to critically assess the weight loss advice provided by their doctors. Studies have indicated that fewer than one-half of overweight and obese patients are advised to lose weight by their doctors (2,13– 15), and only a small percentage believe that the advice that they receive is positive or useful (16). At the same time, the perception among patients is that physicians

Table 4. Weight loss from baseline of participants completing 3 and 6 months

Baseline weight (kg) Weight lost at 3 months (kg) Weight lost at 6 months (kg)

Men

Women

107.5 ⫾ 20.4 (n ⫽ 50) ⫺2.7 (n ⫽ 33) ⫺7.0 (n ⫽ 26)

90.7 ⫾ 20.8 (n ⫽ 202) ⫺4.2 (n ⫽ 123) ⫺8.6 (n ⫽ 94)


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have a high degree of expertise and, therefore, do have the ability to influence the lifestyles and eating habits of their patients. Because of their high perceived expertise and their ability to reach nearly all segments of the population, primary care physicians are in a unique position to provide nutrition information to patients, compared with dietitians (9). Patients with productive interactions with clinicians have improved nutritional care and are more likely to report receiving help with eating problems (17). Advice from a physician to make lifestyle changes may prime patients to become more aware of and attentive to health information. However, although there are many printed educational materials available, establishing a link between written materials and physician advice is an important first step in establishing an officebased system for weight management and disease prevention. Patients who receive physician advice for lifestyle change within a coordinated system of support and information delivery perceive that advice as individualized and are more likely to attempt behavior change (18). Physician training in the effective sharing of information and continuous involvement of the client in the interaction should be stressed over the more traditional prescriptive approach to medical management of weight. In a busy office setting, physicians need brief, direct encounters with their patients regarding weight, and brief yet direct interactions have been shown to be effective (19 –21). However, physician training in counseling techniques alone seems to be insufficient compared with training in nutritional counseling coupled with a structured environment for nutrition management (22). Appropriate training in counseling skills can increase physician confidence and self-efficacy (23). The provision of telephone dietitian counseling coupled with patient education materials and physician education provides an integrated program that facilitates effective physician-delivered nutrition counseling. Follow-up by telephone has been shown to be effective in a variety of situations (24 –27) and can be a convenient and costeffective method for ongoing patient care. Our model suggests that a brief, effective physician-directed program, with telephonic nutritionist support, can be implemented in the setting of a busy primary care office and that physicians can experience a high degree of satisfaction by following a training program in effective counseling and with the provision of appropriate program support.

Acknowledgments This project is supported by an unrestricted grant from Slim-Fast Foods Company. Theresa Clemens was responsible for data management on this project. 324S


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