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Ayaz Virji, MD Sharon E. Philips, MSPH Abstract: Background: Obesity is a chronic disease that has reached
epidemic proportions in the United States. Sixty-seven percent of the
U.S. population is either overweight or obese and the number continues
to rise. Introduction: Obesity is a chronic disease that has reached epidemic proportions in the United States. Sixty-seven percent of the U.S. population is either overweight or obese and the number continues to rise (1). According to the surgeon general of the Public Health Service, these alarming trends in overweight and obesity threaten to overturn many of the improvements achieved in the health of Americans in recent decades (2). Obesity-related comorbidities include coronary heart disease, diabetes mellitus, sleep apnea, debilitating osteoarthritis, and various forms of cancer (3,4,5). An important aspect of any comprehensive weight loss program is the ability of its participants to sustain weight loss over a long period of time. Commercial weight loss programs or dietary formulas which provide an initial jolt to weight loss without appropriate attention given to the need for weight maintenance will likely not provide the solution for the current "globesity" epidemic. Weight cycling not only damages patient self-efficacy, but may also increase the risk of developing a number of medical comorbidities including cholelithiasis, hypertension, and hyperlipidemia (6,7,8). Studies suggest that weight recidivism remains a problem, and only about 25% of obese patients maintain long-term weight loss goals (9). According to the National Institutes of Health (NIH), sustained weight loss of as little as 5-10% of initial body weight has a significant impact in improving obesity-related comorbidities including diabetes, coronary artery disease, and obstructive sleep apnea (10,11). In a previous study, we were able to demonstrate that a comprehensive, evidence-based, 6-step weight management program was successful in achieving short-term weight loss goals in a sample of obese patients (12). The purpose of this study was to test the efficacy of the program in achieving sustained weight loss over a 1-year period of time. Subjects and Methods: This study took place at the Morton Plant Mease Primary Care Weight Management Clinic in Clearwater, Florida. In order to address the rising threat of obesity in this primary care clinic population, a weight management program was adopted based on an evidence-based 6-step methodology for weight management. The study was approved for institutional review board (IRB) review exemption by the Morton Plant Mease IRB. We conducted a retrospective, observational chart review on January 28, 2005 on patients who were originally enrolled in the weight management program who had a body mass index (BMI) of 30 or greater. In the original short-term study, weight loss ranged from 6 to 42 pounds with an average loss of 16.8 pounds (p<0.0001) over a 3-month period (12). The percent of weight loss ranged from 1.7% to 14.4% with an average loss of 6.5%. The average beginning and ending BMI values were 41 and 38 respectively (12). Since obesity is strongly correlated to hyperlipidemia and liver disease, we also measured certain metabolic parameters including: low-density lipoprotein (LDL), high-density lipoprotein (HDL), triglycerides, alanine aminotransferase (ALT), and aspartate aminotransferase (AST). Seven of the initial 15 patients were compliant with pre- and post-laboratory testing and/or had no change in medication that could have affected the measured parameters. Patients enrolled in the 6-Step Methodology Program initially underwent a medical screening to ensure no medical or psychological barriers for weight loss were present. Patients were educated about the physiology of weight loss and weight maintenance to improve self-efficacy. A structured diet was individualized for each patient based on prior success/failure with a particular diet and also patient preference of qualitative versus quantitative diet. Most chose a diet based on low glycemic index foods. During office visits, study patients participated in cognitive and behavioral therapy, which focused on goal setting, understanding obesity as a disease with real medical consequences, activity modification, and identifying environmental eating cues. A plan for weight maintenance was employed based on a 5-10% weight loss over 3 months followed by a 3-month weight maintenance cycle. In the current study, we conducted a chart review of the original patients to determine their most recent documented weight according to their Morton Plant Mease Primary Care (MPMPC) charts. Since most patients were MPMPC clinic patients, we were able to access this information despite their having graduated or having left the MPMPC weight management program. This method was chosen in order to minimize scale-to-scale variability resulting from phone calls and verbal reports of current weight status. We resorted to patient self-reported weights only if there were no recent clinic visits or documentation in the primary care physician's chart to refer to. The average length of follow-up was 12 months. The follow-up
period ranged from 7 months to 21 months. Data was collected for 13
of the original 15 study patients (87% retention rate). Two were lost
to follow-up, having either left the MPMPC clinic or having not responded
to phone calls. Two of the remaining 13 patients had no recent clinic
visits to their primary care provider and so were contacted by phone
for a self-reported weight check Results: Of the 13 participants with follow-up data, 10 (77%) either
continued to lose weight or maintained their weight loss, while 3 people
gained weight and were heavier than when they began the program (Figure
1). The average weight change ranged from a gain of 4 to a loss of 77
pounds, with an average loss of 23 pounds (p=0.013) (Figure 2). The
10 participants who continued to lose weight had an average sustained
loss of 33 pounds (p=0.003) and the average weight gain for the remaining
3 participants was 8 pounds (p=0.133) (Figure 3). The percent of weight
lost ranged from a gain of 4.3% to a loss of 29.9%. Bariatric medicine is the science of weight management, which provides a comprehensive approach to both the short-term and long-term needs of the obese patient. Achievement of long-term weight maintenance goals is a crucial component of any comprehensive bariatric program. In this current study, we were able to demonstrate that our clinic's adopted 6-step methodology approach to weight management was effective in sustaining weight loss goals in 77% of patients for 1 year since enrollment. Our findings underscore the need for comprehensive, longitudinal care in the treatment of the obese patient. Prior studies have demonstrated that routine, longitudinal exposure to a weight management specialist is an independent predictor for long-term weight loss success (13). The U.S. Preventive Services Task Force (USPSTF) recommends that intensive weight management visits occur at least monthly on a one-to-one basis to be effective (14). In our 6-step program, patients are seen for individualized visits every 3 weeks for the first 3 months then every 6 weeks for the next 3 months. Emphasis is placed on patient education, behavioral modification, cognitive restructuring, and on setting a specific, clearly defined weight maintenance strategy focused on relapse prevention. Our study was limited in its small sample size and its observational retrospective design. Ideally, a large, randomized, controlled trial with control group should be implemented to test the long-term weight maintenance goals in our patients. We were unable to obtain current documented weights on two of the 13 follow-up patients and resorted to less desirable self-reported weights for these two patients. The obesity epidemic continues to threaten the health and lives of our patients. As health care professionals it is important that we not "subcontract" out obesity treatment to quick-fix programs that may not offer our patients the comprehensive support required to manage this disease. Individualized, evidence-based treatment programs, which focus on sustaining long-term weight loss goals are the best models to follow when approaching obesity management.
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6-Step
Weight Loss Center
Crownpoint Center, 13191 Starkey Rd, Suite 3, Largo, FL 33773 Phone: +1 727-507-7100 |