No studies have yet assessed the efficacy of intensive behavioral weight-loss counseling delivered in the primary care setting in accordance with Medicare/Medicaid requirements, according to a systematic review of the literature published online Nov. 4 in JAMA.

The U.S. Preventive Services Task Force recommends that all primary care physicians screen all their adult patients for obesity and offer the affected patients such intensive counseling, either by providing it themselves or by referral, said Thomas A. Wadden, Ph.D., of the Center for Weight and Eating Disorders, University of Pennsylvania, Philadelphia, and his associates.

In 2011, the Centers for Medicare & Medicaid Services (CMS) approved the provision of intensive behavioral counseling for obese beneficiaries seen in primary care practices for approximately 14 face-to-face sessions over 6 months when delivered by physicians and other select practitioners. While the CMS covers the costs of such counseling, it does so only when counseling meets specifics on treatment intensity, who may provide it, and where it may be provided.

In their systematic review, the investigators identified 3,304 articles on the topic, and winnowed their detailed review to 12 good-quality trials involving 3,893 participants. They found that to date, not a single study has assessed even one real-world primary care practice that complies with all the CMS requirements.

Data from two of the reviewed clinical trials supported the “treatment intensity” requirement, which is that intensive behavioral weight-loss counseling must include approximately 14 face-to-face sessions during the initial 6 months: weekly sessions for the first month, every-other-week sessions for months 2-6, and monthly sessions during months 7-12. In these two studies, participants attended three sessions with the primary care physician and eight with a trained interventionist for 6 months, and achieved mean weight losses of 4.4 kg and 3.5 kg, respectively.

However, one of these trials substituted brief telephone sessions with trained interventionists at a call center for face-to-face interviews, with good results. “A growing literature suggests that telephone-delivered counseling is generally as effective as traditional face-to-face contact, potentially is more convenient and less costly for patients, and can reach more individuals in underserved areas,” Dr. Wadden and his associates said (JAMA 2014 Nov. 4 [doi: 10.1001/jama.2014.14173]).

Similarly, data from three trials supported the requirement that counseling be provided by trained medical assistants in collaboration with primary care physicians. Weight loss achieved with this approach was far greater than that achieved with counseling provided by trained interventionists who had limited or no collaboration with the primary care physicians. The results of several trials confirmed the requirement that this counseling must be comprehensive, incorporating a dietary component, an exercise component, and a behavioral component to maximize results. In particular, interventions that provided specific goals for energy restriction and expenditure were successful, whereas those that did not were unsuccessful, the investigators said.

This study was funded in part by a grant from the National Institute of Diabetes and Digestive and Kidney Diseases. Dr. Wadden and his associates reported ties to Novo Nordisk, Nutrisystem, Orexigen, Shire Pharmaceuticals, and Weight Watchers.


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