Obesity: Provider Education with a Client Intervention

The CPSTF finding is based on evidence from a systematic review of 8 studies (search period 1966 and June 30, 2007). The review was conducted on behalf of the CPSTF by a team of specialists in systematic review methods, and in research, practice and policy related to obesity prevention and control.

Eight studies were included in the review.

• All of the studies reported patient weight-related outcomes in the desired direction.
  • After 12 months, patients reduced their weight by a median of 2.5 lbs when compared with a control group (5 studies).
  • Studies without a control group showed patients reduced their weight by a median of 11 lbs (range: 6-12 months; 3 studies).
• One study reported provider outcomes and showed that trained providers scored higher on knowledge and were significantly more likely to record a patient’s weight and discuss target weight and diet.

An economic review of this intervention was not conducted because CPSTF did not have enough information to determine if the intervention works.

Applicability of this intervention across different settings and populations was not assessed because CPSTF did not have enough information to determine if the intervention works.

CPSTF identified several areas that have limited information. Additional research and evaluation could help answer the following questions and fill remaining gaps in the evidence base. (What are evidence gaps?)

The following outlines evidence gaps from reviews of provider-oriented interventions to prevent and control obesity: provider education, provider feedback, provider reminders, provider education with a client intervention, multicomponent provider interventions, and multicomponent provider interventions with client interventions.

Future studies should measure changes in provider behavior and patient weight-related outcomes. Studies should be conducted over a clinically meaningful duration, report outcomes with statistical precision, and use a study design and sample size that allows sufficient power to detect a meaningful difference. Following are questions that remain to be answered.

Effectiveness on provider outcomes:

• What effect do education, reminders, and feedback have on providers’ knowledge, attitudes, skills, and behavior?
• Do these interventions have an additional benefit on the provider’s own weight?
• Which characteristics of these interventions contribute to increased or decreased effectiveness?
• Does the method of delivery to providers matter?
• What frequency, duration, or format of provider education contributes to increased or decreased effectiveness?
• Are provider-based interventions more effective at either preventing weight gain, preventing weight re-gain, or promoting weight loss?

Effectiveness on patient outcomes:

• If the provider interventions change their knowledge, attitudes, and skills, does this have an effect on patient knowledge, attitudes, and skills?
• Do provider-level interventions have an effect on patient biological outcomes (such as weight-related outcomes, objectively measured)?
• What are intervention effects on various subgroups/sub-populations?

Implementation and adoption:

• Are provider-level interventions more effective when integrated within clinical systems than when offered on a referral basis?
• Do specific potential benefits from an intervention enhance its acceptability? For example, does training providers on obesity counseling assist with other types of counseling?
• Are there other harms from an intervention, such as taking time away from other tasks that might be more effective?
• What is the cost effectiveness of these interventions?
• How broadly applicable is the intervention; to what types of patients does it appeal?
• What resources (e.g., time, money, staffing, computer capabilities) constrain these interventions?
• What are the barriers and enabling factors to adoption and implementation of provider-level interventions? In what ways can they be integrated into institutional or other systems-level interventions?
• Does effectiveness differ based on the level of scale in which interventions are delivered or on type of provider?

• Five studies used randomized controlled trials and three used a pre-post design.
• Provider education varied by who conducted the education, for how long, and on what topics. Patient interventions included education and counseling.
• Patient characteristics included diabetes, hypertension, and obesity.

Effectiveness Review

• For Adults
• For Children

When starting an effectiveness review, the systematic review team develops an analytic framework. The analytic framework illustrates how the intervention approach is thought to affect public health. It guides the search for evidence and may be used to summarize the evidence collected. The analytic framework often includes intermediate outcomes, potential effect modifiers, potential harms, and potential additional benefits.

Effectiveness Review

Summary Evidence Table — Effectiveness Review

The number of studies and publications do not always correspond (e.g., a publication may include several studies or one study may be explained in several publications).

Effectiveness Review

Cohen MD, D’Amico FJ, Merenstein JH. Weight reduction in obese hypertensive patients. Fam Med 1991;23:25-8.

Kastarinen MJ, Puska PM, Korhonen MH, et al. for the LIHEF Study group. Non-pharmacological treatment of hypertension in primary health care: a 2-year open randomized controlled trial of lifestyle intervention against hypertension in eastern Finland. J Hypertens 2002;20(12):2505-12.

Lojander J, Mustajoki P, Ronka S, Mecklin P, Maasilta P. A nurse-managed weight reduction programme for obstructive sleep apnoea syndrome. J Intern Med 1998;244:251-5.

Moore H, Summerbell CD, Greenwood DC, et al. Improving management of obesity in primary care: cluster randomized trial. BMJ 2003;327:1085-9.

Ockene IS, Hebert JR, Ockene JK, et al.. Effect of physician-delivered nutrition counseling training and an office-support program on saturated fat intake, weight, and serum lipid measurements in a hyperlipidemic population. Arch Intern Med 1999, 159:725-31.

Richman RM, Webster P, Mira M, Steinbeck KS, Caterson ID. A shared care approach in obesity management: the general practitioner and a hospital based service. Int J Obes 1996;29:413-9.

Willaing I, Ladelund S, Jorfensen T, Simonsen T, Nielson LM. Nutritional counseling in primary health care: a randomized comparison of an intervention by general practitioner or dietician. Eur J Cardiovasc Prev Rehabil 2004;11:513-20.

Woollard J, Burke V, BeilinThe number of studies and publications do not always correspond (e.g., a publication may include several studies or one study may be explained in several publications). LJ, Verheijden M, Bulsara MK. Effects of a general practice-based intervention on diet, body mass index and blood lipids in patients at cardiovascular risk. J Cardiovasc Risk 2003;10(1):31-40.

The following outlines the search strategy used for evidence reviews of provider-oriented interventions to prevent and control obesity: provider education, provider feedback, provider reminders, provider education with a client intervention, multicomponent provider interventions, and multicomponent provider interventions with client interventions.

Using Medical Subject Headings and text words, in July 2007 we searched the following databases: Medline, Embase, LILACS, PsycInfo, CINAHL, Dissertation Abstracts, and Cochrane. We used search terms related to provider/medical care combined with terms related to weight and overweight. The specific search terms used are shown on the Community Guide website. Experts in obesity and/or provider-based interventions were consulted for citations, and reference lists of retrieved articles and literature reviews were also reviewed.

Searches were limited to literature published in English-language journals between 1966 and June 30, 2007. To be considered for inclusion, studies had to (1) report on one or more outcomes identified in our analytic framework, specifically either a provider behavior and/or patient weight-related data from 6 months from the start of the intervention; and (2) meet the definition of a provider-level intervention. We excluded studies specifically targeting pregnant or post-partum populations.

Effectiveness Review

Search Terms

General search

Limited to humans, English language, and not review

Databases: Medline, Embase, CINAHL, PsycINFO, WOS, SPORTDiscus, ERIC

Terms: BMI (or body mass index)/ obesity (or obese)/ over weight (or overweight)/ body weight + delivery of health care/ quality of health care/ professional practice+ exercise/ physical activity/ nutrition disorders/ nutrition assessment/ nutrition/ nutrition therapy

Cost benefit/ cost-benefit analysis/ cost effectiveness/ effectiveness OR evaluation/ evaluation studies/ outcome assessment/ outcome and process assessment

Provider education specific search

Databases: Medline, PsycInfo, Nexis-Lexis, Embase, CINAHL, Sportdiscus, WOS, Cochrane (DARE, CENTRAL), Dissertation abstracts international, Health promotion and education, LILACS, POPLine, and HealthStar.

Terms: BMI (or body mass index)/ obesity (or obese)/ percent body fat/ weight/ overweight + provider/physician + education/tools/training

Behavioral specific search

Databases: Medline, PsycInfo, Embase, CINAHL, Sportdiscus, Cochrane (DARE, CENTRAL), Dissertation abstracts international, Health promotion and education, LILACS, POPLine, and HealthStar.

Terms:

BMI (or body mass index)/ obesity (or obese)/ body fat/ weight/ overweight

+ exercise/ physical activity/ fitness/ nutrition assessment/ nutrition/ nutrition therapy

+ behavioral/ behavior modification/ self management/ counseling/ education/ support/

+ medical (or health) care/ hospital/ clinic/ general (or family) practice/ provider/ physician/ nurse/ patient/

Technology specific search

Databases: Medline, PsycInfo, Embase, CINAHL, Sportdiscus, Cochrane (DARE, CENTRAL), Dissertation abstracts international, Health promotion and education, LILACS, POPLine, and HealthStar.

Terms:

BMI (or body mass index)/ obesity (or obese)/ body fat/ weight/ overweight

+ medical (or health) care/ hospital/ clinic/ general (or family) practice/ provider/ physician/ nurse/ patient/

+ Internet/ web/ website / message (or discussion) board/ chat/ telephone (or telephony)/ cellphone/ compact disc / digital versatile (or video) disc (or dvd)/ electronic/ interactive voice response (or IVR)/ computer/ touch screen/ interactive/ personal digital assistant (or PDA)/ palm pilot/ pocket pc/ software/ email (or e-mail)

Additional Search Methods

In addition to the library-assisted search, review articles were flagged for review to search their reference lists (an “ancestry search”).

Ovid MEDLINE(R)

1. (educat$ or train$).hw,tw. or ed.fs.
2. exp health personnel/ or family practice/ or primary health care/ or physician$.mp. or nurs$.mp. or pharmac$.mp. or health care provider$.mp.
3. 1 and 2
4. exp Overweight/
5. exp obesity/
6. body mass index/ or skinfold thickness/ or waist-hip ratio/
7. bmi.tw. or obes$.mp.
8. weight$.hw,tw. or body fat.tw. or overweight.mp.
9. or/4-8
10. 3 and 9
11. limit 10 to english language
12. limit 11 to humans

EMBASE

1. ‘education’/exp OR educat* OR training OR train* OR ‘reminder system’/de OR ‘feedback system’/exp OR remind* OR feedback OR ‘feed back’ AND [english]/lim AND [humans]/lim AND [embase]/lim AND [1966-2007]/py
2. ‘health care personnel’/exp OR ‘medical care’/exp OR ‘primary health care’/exp OR ‘general practice’/exp OR physician* OR nurs* OR pharmacist* OR ‘health care provider’ AND [english]/lim AND [humans]/lim AND [embase]/lim AND [1966-2007]/py
3. ‘body mass index’ OR ‘bmi’ OR ‘overweight’ OR ‘weight’ OR ‘body fat’ OR obes* OR ‘obesity’/exp OR ‘body mass’/de OR ‘waist hip ratio’/de OR ‘skinfold thickness’/de AND [english]/lim AND [humans]/lim AND [embase]/lim AND [1966-2007]/py
4. 1 AND 2 AND 3

CINAHL

1. (educat$ or train$).hw,tw. or ed.fs.
2. exp health personnel/ or family practice/ or primary health care/ or physician$.mp. or nurs$.mp. or pharmac$.mp. or health care provider$.mp.
3. 1 and 2
4. exp Overweight/
5. exp obesity/
6. body mass index/ or skinfold thickness/ or waist-hip ratio/
7. bmi.tw. or obes$.mp.
8. weight$.hw,tw. or body fat.tw. or overweight.mp.
9. or/4-8
10. 3 and 9
11. limit 10 to english language
12. limit 11 to humans [Limit not valid in: CINAHL; records were retained]
13. limit 12 to yr=”1966 – 2007″
14. 13 not 200707$.ew.

DIALOG

Dissertation Abs Online

1. 166 ((EDUCAT? OR TRAIN? OR FEEDBACK OR REMIND?) AND (PHYSICIAN? OR NURS? OR PHARMAC?) AND (OVERWEIGHT OR OBES? OR BMI)) AND PY=1966:2007
2. 166 Sort S1/1-500/PY,D
3. 166 S2
4. 164 RD S3/1-5000 (unique items)

COCHRANE

“educat* or train* or remind* or feedback or “feed back” in Title, Abstract or Keywords and “health personnel” or “family practice” or “primary health care” or physician* or nurs* or pharmac* or “health care provider*” in Title, Abstract or Keywords and overweight or obes* or bmi or “body mass index” or “skinfold thickness” or “waist-hip ratio” or weight or “body fat” in Title, Abstract or Keywords

PsycINFO

1. (educat$ or train$).hw,tw. (407505)
2. exp health personnel/ or family medicine/ or primary health care/ or physician$.mp. or nurs$.mp. or pharmac$.mp. or health care provider$.mp. (138179)
3. 1 and 2 (33083)
4. obesity/ (6534)
5. body mass index/ or skinfold thickness.tw. or waist-hip ratio.tw. (439)
6. bmi.tw. or obes$.mp. (11038)
7. weight$.hw,tw. or body fat.tw. or overweight.mp. (41558)
8. or/4-7 (46143)
9. 3 and 8 (456)
10. limit 9 to (human and english language) (409)
11. limit 10 to yr=”1966 – 2007″ (404)
12. 11 not 200707$.up. (403)
13. from 12 keep 1-403 (403)

LILACS

educat$ or train$ or feedback or “feed back” or reminder$ [Palavras] and doctor$ or nurs$ or pharmac$ or “health care provider$” [Palavras] and overweight or obes$ or bmi or “body mass index” or skinfold or weight or “body fat” [Palavras]

CPSTF did not have enough evidence to determine whether the intervention is or is not effective. This does not mean that the intervention does not work, but rather that additional research is needed to determine whether or not the intervention is effective.