Transcript File - Telana N. Fairchild

Telana Fairchild, BSN, RN
University of Massachusetts- Worcester- Graduate School of Nursing
Background and Significance
 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
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
Findings
PICOT
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?
Alexander, et al., 2011: Number of times each of the
“5A’s” were used during provider visits
Asked
48%
Mitchell, et al., 2012: Insurance covered cost for
participants to attend WW for one year.
Weight loss
Motivational Interviewing
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Weight Watchers is a registered trademark of Weight Watchers International, Inc.
Advised
39%
Literature Search
40
35.7%
35
30.5%
≈72.5
million
Percent obese
30
 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)
≈78.6
million
Assisted
8%
Assessed
Arranged 2%
3%
Johnson, et al., 2008: TTM used to target multiple
behaviors vs no treatment
25
Total number of articles obtained using the search terms
20
7,412
15
5
Eliminated duplicate articles
97
128
0
1988-1994
1999-2000
2001-2002
2003-2004
2005-2006
2007-2008
2011-2012
Number of articles after deleting specific populations that
couldn’t be generalized to target population.
NIHHS Treatment Algorithm 1998
AHA/ACC/TOS Treatment Algorithm 2014
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
39
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
>36
Pinto, et al., 2013: Weight change between behavior;
WW and combined
-1
7,187
Number of articles after deleting duplicates
13-24
25-36
Number of meetings
0
Eliminated articles published prior to 2008, without available full text,
subjects other than humans, languages other than English, and ages less
than 17 years.
10
2-12
Weight change (kg)
Adult obesity in United States 1988-2012
14
12
10
8
6
4
2
0
-2
-3
BWL
-4
WW
-5
CT
-6
-7
-8
Baseline I 12 Weeks
I 24 Weeks
I 48 Weeks
58
Eliminated studies which did not evaluate the target independent variables
Jebb, et al., 2011: Comparison of national guidelines
to WW
Fuller, et al., 2012: Cost analysis of Jebb, et al., 2011
19
20
Articles selected for further review
Eliminated studies which did not evaluate the target dependent variable
12
Weight loss was included as a dependent variable
After further review article found not to include weight loss and had poor
representative of the TTM
11
Articles for studies with strong levels of evidence, strong
sample sizes representative of the target population and
reliable and valid data measurements
1
Future Research
Articles eliminated based on poor design, weak level of evidence and
weak sample size
2
9
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
Weight Watchers
General practice
8
Articles found with new search of the aforementioned process
3
 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
12
Recommendations
 As a future provider:
Synthesis
Scenario
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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
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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
• 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
References:
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 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
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
Education and Counseling, 89, p. 152-157. Elsevier Ireland Ltd: ScienceDirect. Retrieved from http://dx.doi.org/10.1016/j.pec.2012.06.033
(4), p. 673-680.
Watchers by the NHS. BioMedCenteral: Public Health, 11. Retrieved from http://www.biomedcenteral.com/1471-2458/11/434
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 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
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
of Medicine, 125 (6), p. 603.e7-603.e11. doi: 10.1016/j.amjmed.2011.07.039
behaviors for employee health promotion. Preventive Medicine, 46 (3), p. 226–31. doi: 10.1016/j.ypmed.2007.11.007
Medicine, 53 (3), p. 179-184.
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- 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
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
884. doi: 10.1037/a0021498.
vitality in adults participating in a cognitive-behavioral weight loss program. Health Psychology, 32, (4), p. 439-446. American Psychological Association. doi:
loss in overweight and/or obese patients: A systematic review and meta-analysis of randomized controlled trails. Obesity Reviews: International Association for the 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
10.1037/a0029186.
Study of Obesity, 12, p. 709-723. doi: 10.1111/j.1467-789X.2011.00892.x
standard care: A randomized controlled trial. The Lancet, 378, p. 1485-92. doi: 10.1016/S0140-6736(11)61344-5.
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
Centers for Disease Control and Prevention (CDC): Chronic Disease Prevention and Health Promotion. (2011). Obesity: Halting the epidemic by making health easier at a
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
overweight and obese adults (Review). Cochrane Database of Systematic Reviews, 10. doi: 10.1002/14651858.CD008066.pub2.
glance 2011. Retrieved from: http://www.cdc.gov/chronicdisease/resources/publications/AAG/obesity.htm
adults. Circulation (accepted manunscript). doi: 0.1161/01.cir.0000437739.71477.ee
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
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 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
Nursing, 24 (1), p. 58-80.
Company.
weight management: Effectiveness on a population basis. Preventive Medicine, 46, p. 238-246.
United States Department of Health and Human Services (USDHHS): National Heart, Lung and Blood Institute. (1998). Clinical guidelines on the identification, evaluation, and
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 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
treatment of overweight and obesity in adults: The evidence report. Retrieved from: http://www.nhlbi.nih.gov/guidelines/obesity/ob_gdlns.pdf
to gathering, evaluating, and recording the evidence. American Journal of Nursing, 110 (7), 47-52
physician weight counseling. Medical Care, 51 (2), p.186-192.
United States Department of Health and Human Services (USDHHS): Health People 2020. (2012). Nutrition and weight status. NSW-9. Retrieved from:
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 – Lai, D.T.C, Cahill, K., Qin, Y., & Tang, J.L. (2010). Motivational interviewing for smoking cessation. Cochrane Database of Systematic Reviews,10. doi:
http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicId=29
examining the “keeper” studies. American Journal of Nursing, 110 (9), p.41-48
10.1002/14651858.CD006939.pub2.
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
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), 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.
practice. New England Journal of Medicine, 365 (21), p. 1969-79. doi: 10.1056/NEJMoa1109220
p. w822-w831. doi: 10.1377/hlthaff.28.5.w822
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.
World Health Organization (WHO). (2013). Obesity: Fact sheet on obesity and overweight. Retrieved from http://www.who.int/topics/obesity/en/
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
Journal of General Internal Medicine, 23 (1), p. 12-17. doi: 10.1007/s11606-012-2083-8.
commercial provider for weight loss treatment, relative to standard care: An international randomised controlled trial. International Journal of Obesity, 37,
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
p. 828-834. doi: 10.1038/ijo.2012.139.
Promotion. National Center for Health Statistics (NCHS): NCHS data brief, number 82. Retrieved from: http://www.cdc.gov/nchs/data/databriefs/db82.pdf
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.