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-8 -7 -6 -5 -4 -3 -2 -1 0 BWL WW CT Baseline I 12 Weeks I 24 Weeks I 48 Weeks Weight change (kg) Effective Method for Controlling Adult Obesity Telana Fairchild, BSN, RN University of Massachusetts- Worcester- Graduate School of Nursing How does the Primary Care Provider guided behavior modification, transtheoretical model- stages of change (TTM SOC), for diet and physical activity for the obese (BMI ≥ 30kg/ m2 ) adult patients (seventeen years and older) compare to a standard commercial weight loss program, Weight Watchers (WW) concerning weight loss of at least five percent in three months and maintenance for at least year? Databases: PubMed, Cochran Library, and Ovid Terms: “obesity AND motivational interviewing,” “obesity AND transtheoretical model,” “obesity AND weight watchers,” “obesity treatment AND primary care,” and “obesity AND five A’s” (7,412) Future Research Findings 55 year old gentleman CPE- seven years ago Lost sister this past month r/t MI PMHx: None SHx: None Medications: None Family Hx: heart disease, colon and breast CA, and diabetes Diet: fast food restaurant, skips breakfast, pasta, meat, potatoes. Denies fruit and vegetables. Drinks soda and coffee with cream and sugar. Limited water intake. Exercise: none, no interest. Today: BMI: 35kg/m2, B/P: 164/83 and total cholesterol: 284. Dx: Obesity, HTN, HL References: Ahern, A.L, Olson, A.D, Aston, L.M., & Jebb, S.A. (2011). Weight Watchers on prescription: An observational study of weight change among adults referred to Weight Watchers by the NHS. BioMedCenteral: Public Health, 11. Retrieved from http ://www.biomedcenteral.com/1471-2458/11/434 Alexander, S.C., Cox, M. E., Boling-Turer, C.L., Lyna, P., Østbye, T., Tulsky, J.A., … Pollak, K.I. (2011). Do the five A’s work when physicians counsel about weight loss? Family Medicine, 53 (3), p. 179-184. Armstrong, M.J., Mottershead, T.A., Ronksley, P.E., Sigal, R.J., Campbell, T.S., & Hemmelgarn, B.R. (2011). Obesity management: Motivational interviewing to improve weight loss in overweight and/or obese patients: A systematic review and meta-analysis of randomized controlled trails. Obesity Reviews: International Association for the Study of Obesity, 12, p. 709-723. doi: 10.1111/j.1467-789X.2011.00892.x Centers for Disease Control and Prevention (CDC): Chronic Disease Prevention and Health Promotion. (2011). Obesity: Halting the epidemic by making health easier at a glance 2011. Retrieved from: http://www.cdc.gov/chronicdisease/resources/publications/AAG/obesity.htm Dunphy, L.M, Winland-Brown, J.E., Porter, B.O., & Thomas, D.J. (2011). Primary care: The art and science of advanced practice nursing (3rd ed.). Philadelphia, PA: F.A. Davis Company. Fineout-Overholt, E., Melnyk, B.M., Stillwell, S.B., & Williamson, K.M. (2010). Evidence-based practice: Step by step: Critical appraisal of the evidence: Part I: An introduction to gathering, evaluating, and recording the evidence. American Journal of Nursing, 110 (7), 47-52 Fineout-Overholt, E., Melnyk, B.M., Stillwell, S.B., & Williamson, K.M. (2010). Evidence-based practice: Step by step: Critical appraisal of the evidence: Part II: Digging deeper – examining the “keeper” studies. American Journal of Nursing, 110 (9), p.41-48 Finkelstein, E.A., Trogdon, J.G., Cohen, J.W., & Dietz, W. (2009). Estimates annual medical spending attributable to obesity: Payer-and service-specific. Health Affairs, 28 (5), p. w822-w831. doi: 10.1377/hlthaff.28.5.w822 Gudzune, K.A., Clark, J.M., Appel, L.J., & Bennett, W.L. (2012). Primary care providers’ communication with patients during weight counseling: A focus group study. Patient Education and Counseling, 89, p. 152-157. Elsevier Ireland Ltd: ScienceDirect. Retrieved from http://dx.doi.org/10.1016/j.pec.2012.06.033 Haas, W.C., Moore, J.B., Kaplan, M., & Lazorick, S. (2012). Outcomes from a medical weight loss program: Primary care clinics versus weight loss clinics. The American Journal of Medicine, 125 (6), p. 603.e7-603.e11. doi: 10.1016/j.amjmed.2011.07.039 Hettema, J.E., & Hendricks, P.S. (2010). Motivational interviewing for smoking cessation: A meta-analytic review. Journal of Consulting and Clinical Psychology, 78 (6), p.868-884. doi: 10.1037/a0021498. Jebb, S.A., Ahern, A.L, Olson, A.D., Aston, L.M., Holzapfel, C., Stoll, J.,…, Caterson, I.D. (2011). Primary care referral to a commercial provider for weight loss treatment versus standard care: A randomized controlled trial. The Lancet, 378, p. 1485-92. doi: 10.1016/S0140-6736(11)61344-5. Jensen, M.D., Ryan, D.H., Apovian, C.M., Loria, C.M., Ard, J.D., Millen, B.E.,…, Yanovski, S.Z. (2013). AHA/ACC/TOS Guideline for the management of overweight and obesity in adults. Circulation (accepted manunscript). doi: 0.1161/01.cir.0000437739.71477.ee Johnson, S.S., Paiva, A.L., Cummins, C.O., Johnson, J.L., Dyment, S.J., Wright, J.A.,… & Sherman, K. (2008). Transtheoretical model-based multiple behavior intervention for weight management: Effectiveness on a population basis. Preventive Medicine, 46, p. 238-246. Kraschnewski, J.L, Sciamanna, C.N., Stuckey, H.L., Chuang, C.H., Lehman, E.B., Hwang, K.O., … Nembhard, H.B. (2013). A silent response to the obesity epidemic: Decline in US physician weight counseling. Medical Care, 51 (2), p.186-192. Pinto, A.M., Fava, J.L., Hoffmann, D.A., & Wing, R.R. (2013). Combining behavioral weight loss treatment and a commercial program: A randomized clinical trial. Obesity, 21 (4), p. 673-680. Prochaska, J.O., Butterworth, S., Redding, C.A., Burden, V., Perrin, N., Leo, M., … & Prochaska, J.M. (2008). Initial efficacy of MI, TTM tailoring and HRI’s with multiple behaviors for employee health promotion. Preventive Medicine, 46 (3), p. 226–31. doi: 10.1016/j.ypmed.2007.11.007 Swencionis, C., Wylie-Rosett, J., Lent, M.R., Ginsberg, M., Cimino, C., Wassertheil-Smoller, S., …& Segal-Isaacson, C-J. (2012). Weight change, psychological well-being, and vitality in adults participating in a cognitive- behavioral weight loss program. Health Psychology, 32, (4), p. 439-446. American Psychological Association. doi: 10.1037/a0029186. Tuah, N.A.A., Amiel, C., Qureshi, S., Car, J., Kaur, B., & Majeed, A. (2011). Transtheoretical model for dietary and physical exercise modification in weight loss management for overweight and obese adults (Review). Cochrane Database of Systematic Reviews, 10. doi: 10.1002/14651858.CD008066.pub2. Turk, A.W., Yang, K., Hravnak, M., Sereika, S.M., Edwing, L.J., & Burke, L.E. (2009). Randomized clinical trials of weight loss maintenance: A review. Journal of Cardiovascular Nursing, 24 (1), p. 58-80. United States Department of Health and Human Services (USDHHS): National Heart, Lung and Blood Institute. (1998). Recommendations 1988-1994 1999-2000 2001-2002 2003-2004 2005-2006 2007-2008 2011-2012 0 5 10 15 20 25 30 35 40 Adult obesity in United States 1988-2012 Percent obese 30.5% Weight Watchers is a registered trademark of Weight Watchers International, Inc. M I Motivational Interviewing Obesity: body mass index (BMI) (≥30kg/m 2 ) 2012- 35.7% of adult US- an increase 2008 cost ≈ $147 billion Mortality risk of BMI ≥ 35kg/m 2 = 40- 60% WHO: national concern, all ethnicities, all demographics, and all ages Preventable and modifiable condition Contributes to several chronic and comorbid illnesses Health People 2020: weight reductions of 5-20% 5-20% significantly decrease morbidity associated with obesity NIHHS treatment guidelines from 1998 Accepted manuscript for new guidelines 2013 ≈78.4 million obese adults- slight decrease Background and Significance 35.7% NIHHS Treatment Algorithm 1998 AHA/ACC/TOS Treatment Algorithm 2014 Scenario PICOT Total number of articles obtained using the search terms 7,412 Eliminated articles published prior to 2008, without available full text, subjects other than humans, languages other than English, and ages less than 17 years. 7,187 Number of articles after deleting duplicates 97 Eliminated duplicate articles 128 Number of articles using TTM SOC or similar behavioral change model (MI, 5A’s), Provider/physician guided, or WW or similar program as the independent variables 20 Articles selected for further review 12 Eliminated studies during a review of the abstract that included specific populations of subjects based on ethnicity, culture, or health condition instead of target population 58 Eliminated studies which did not evaluate the target independent variables 19 Articles eliminated based on poor design, weak level of evidence and weak sample size 2 Articles for studies with strong levels of evidence, strong sample sizes representative of the target population and reliable and valid data measurements 9 Number of articles after deleting specific populations that couldn’t be generalized to target population. 39 Eliminated studies which did not evaluate the target dependent variable 8 After further review article found not to include weight loss and had poor representative of the TTM 1 Weight loss was included as a dependent variable 11 Articles found with new search of the aforementioned process 3 Newest literature search included additional studies with strong levels of evidence, strong sample sizes representative of the target population and reliable and valid data measurements 12 Literature Search Synthesis Level of evidence: I-VI, most II Reliable internal validity Bias unlikely Target outcome 5-10% reduction Population: Caucasian, females, 30-40’s, BMI 35-38kg/m 2 New guidelines are supported MI and WW together Influential factors: willingness, adherence, and accuracy, ethnicity, time, cost WW and number of session (adherence) Compared: WW ≥ MI Weight loss involves multiple behaviors Use of all 5 A’s As a future provider: • Patient-centered treatment using MI • Understand barriers • Use WW program when possible • Or use similar plan using nursing visits and nutritionist Insurance companies need to cover cost For R.M.: referral to the WW program for weekly sessions with PCP behavior guided modifications biweekly until 10% weight loss is achieved. Needs weight reduction of 30% from his current baseline achieve 10% reevaluate his need and desire to continue his weight loss regimen using MI and treat accordingly with the goal of another 10% until normal weight is achieved. Target outcome should be weight reduction as there is proof this will lead to reduction of other chronic illness and comorbidities Need to include all demographics and ethnicities For understanding weight loss maintenance, research should look at 5- 10yrs If MI is researched use a tool to measure appropriate use and application of MI More focus now on cost as well, insurance companies need to consider covering cost of these visits or at least reducing cost Johnson, et al., 2008: TTM used to target multiple behaviors vs no treatment 2-12 13-24 25-36 >36 0 4 8 12 Number of meetings Weight loss Jebb, et al., 2011: Comparison of national guidelines to WW Fuller, et al., 2012: Cost analysis of Jebb, et al., 2011 Alexander, et al., 2011: Number of times each of the “5A’s” were used during provider visits Advised 39% Assessed 2% Arranged 3% Assisted 8% Asked 48% Mitchell, et al., 2012: Insurance covered cost for participants to attend WW for one year. Pinto, et al., 2013: Weight change between behavior; WW and combined Weight Watcher General practice ≈72.5 million ≈78.6 million
