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M. I. Effective Method for Controlling Adult Obesity. Telana Fairchild, BSN, RN University of Massachusetts- Worcester- Graduate School of Nursing. Weight Watchers is a registered trademark of Weight Watchers International, Inc. Motivational Interviewing. Findings. PICOT. - PowerPoint PPT Presentation
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Effective Method for Controlling Adult ObesityTelana 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/1471-2458/11/434Alexander, 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
Fuller, N.P., Colagiuri, S., Schofield, D., Olson, A.D., Shrestha, R., Holzapfel, C.,... & Caterson, I.D. (2013). A within-trial cost-effectiveness analysis of primary care referral to a commercial provider for weight loss treatment, relative to standard care: An international randomised controlled trial. International Journal of Obesity, 37, p. 828-834. doi: 10.1038/ijo.2012.139.
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.
Lai, D.T.C, Cahill, K., Qin, Y., & Tang, J.L. (2010). Motivational interviewing for smoking cessation. Cochrane Database of Systematic Reviews,10. doi: 10.1002/14651858.CD006939.pub2.
Mehta, N.K., & Chang, V.W. (2009). Mortality attributable to obesity among middle-aged adults in the United States. Demography, 46 (4), p. 851-72. Mitchell, N.S., Ellison, M.C., Hill, J.O., & Tsai, A.G. (2012). Evaluation of the effectivness of makin Weight Watchers available to Tennessee Medicaide (TennCare) recipients.
Journal of General Internal Medicine, 23 (1), p. 12-17. doi: 10.1007/s11606-012-2083-8.Ogden, C.L., Carroll, M.D., Kit, B.K., & Flegal, K.M. (2012). Prevalence of obesity in the United States, 2009–2010. Centers for Disease Control and Prevention (CDC): Health
Promotion. National Center for Health Statistics (NCHS): NCHS data brief, number 82. Retrieved from: http://www.cdc.gov/nchs/data/databriefs/db82.pdf
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). Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults: The evidence report. Retrieved from: http://www.nhlbi.nih.gov/guidelines/obesity/ob_gdlns.pdf
United States Department of Health and Human Services (USDHHS): Health People 2020. (2012). Nutrition and weight status. NSW-9. Retrieved from: http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicId=29
Wadden, T.A., Volger, S., Sarwer, D.B.,Vetter, M.L., Tsai, A.G., Berkowitz, R.I., … Moore, R.H. (2011). A two-year randomized trial of obesity treatment in primary care practice. New England Journal of Medicine, 365 (21), p. 1969-79. doi: 10.1056/NEJMoa1109220
World Health Organization (WHO). (2013). Obesity: Fact sheet on obesity and overweight. Retrieved from http://www.who.int/topics/obesity/en/
Recommendations
1988-1994 1999-2000 2001-2002 2003-2004 2005-2006 2007-2008 2011-20120
5
10
15
20
25
30
35
40
Adult obesity in United States 1988-2012
Perc
ent o
bese
30.5%
Weight Watchers is a registered trademark of Weight Watchers International, Inc.MIMotivational Interviewing
Obesity: body mass index (BMI) (≥30kg/m2) 2012- 35.7% of adult US- an increase 2008 cost ≈ $147 billion Mortality risk of BMI ≥ 35kg/m2 = 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.
7,187Number of articles after deleting duplicates
97Eliminated 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/m2
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 >3602468
101214
Number of meetings
Wei
ght l
oss
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
Advised39%
Assessed2%
Arranged3%Assisted
8%
Asked48%
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 WatchersGeneral practice
≈72.5 million
≈78.6million