Transcript Results from the MATRIX Study

The Evidence Base for Effectiveness of
Obesity Management Programs:
A Comprehensive Review of the Literature
Neil Goldfarb
Associate Dean for Research
Joseph Yaskin, M.S.S.
Project Manager
Richard Toner, M.S.
Research Assistant
Jefferson School of Population Health
Philadelphia, PA
Presentation Goals
• Brief Overview of Results
• Clinical Interventions in Context
– Population health
– Role in chronic care management
• Promising Directions for Future Research
• Continuing Research at Jefferson
Obesity and Overweight, U.S.,
20-74 year olds,1980-2006 (% of pop.)
No Significant
Change from
20042
70
60
50
Obese
40
30
Overweight
and Obese
20
10
0
1976- 1988- 1999- 2003- 200580
94 2002 2004 2006
Source: 1. CDC. 2. Ogden C et al. Prevalence of Overweight and Obesity in the United States, 1999-2004. JAMA. April 5, 2006 –
Vol. 295.No.13. 2. Updated with NHANES 2005-06 Data.
Obesity Trends Among U.S. Adults
CDC (BRFSS, 1990, 1998, 2007)
(*BMI 30, or about 30 lbs. overweight for 5’4” person)
1998
1990
2007
No Data
<10%
10%–14%
15%–19%
20%–24%
25%–29%
≥30%
History & Context
• Supported by DMAA: The Care Continuum Alliance
• Component of Obesity with Co-Morbidities Project
• Goals:
• Expand understanding of co-morbid obesity
• Develop and disseminate best practices
• Methods:
• Peer-reviewed literature 2001-2007
• Methods accepted as best practices employed
What We Reviewed
• Intervention categories
– Behavioral
– Pharmaceutical
– Surgical
Note: Population Health Management
interventions partially examined
Preview of Findings
• Effective: Weight-loss interventions
combining two or more mechanisms of
action often effective.
• Not-effective: Pharmacologic and
behavior-based interventions combined
with a second mechanism of action.
Behavioral Interventions
•
•
•
•
•
Exercise
Self-help
Counseling
Diet
Combination of above
Results - Behavior Interventions
• Behavioral interventions may be
appropriate for patients who need to lose
modest amounts of weight. (Stevens, 2001)
• Program intensity and maintenance of
intervention over time associated with
effectiveness
Pharmacologic Interventions
•
•
•
No evidence that one pharmacologic
treatment is superior in effectiveness to
another
No drugs produce placebo-subtracted weight
losses of 10% or more (NIH)
Best results achieved when intensive lifestyle
intervention is coupled with therapy.
Results: Pharmacologic Studies
Our review confirmed previous findings:
1. No studies of anti-obesity medications are associated with
>10%, placebo subtracted, weight loss. 1
2. Medication interventions must be part of a comprehensive
chronic care management strategy. 2
3. Combined with diet and behavioral lifestyle modification,
pharmacologic treatment can yield 5-10% weight-loss. 1
Sources:1: Padwal R.S. Drug Treatments for obesity: orlistat, sibutramine, and rimonabant. Lancet 2007;
2: Bray GA. Medical Therapy for Obesity. Medical Clinics of North America (2007)
Surgical Interventions: Two Types
• Restrictive
– Restricts stomach capacity,
reducing food intake
– Adjustable Gastric
Banding, Vertical Banded
Gastroplasty
Combined Restrictive /
Malabsorptive
– Restricts stomach and
amount of nutrients,
calories absorbted
– Gastric Bypass,
Bileopancreatic Diversion
R: The Cleveland Clinic (www.clevelandclinic.org)
Results: Surgical Interventions
• Supporting evidence is well-established.
• Approach is not appropriate for all
patients.
• Effectiveness hindered by post-operative
complications, costly readmissions.
• Costs: significant initial investment,
attractive ROI (~6 years) with reduction
in co-morbidities.
Summary of Review Results
• Not Effective!
– Any type of intervention administered
without integration of a second type
• Effective!
– Medical OR Surgical interventions WITH:
– strong behavior/lifestyle component, AND
– personal commitment of patient
• Selected stand-alone behavior interventions
– Only long-term interventions (2 yrs +) with frequent
clinical interaction, maximizing “dose effect.”
Obesity and Population Health
• Consensus:
– Obesity is an environmental health problem
• Domains for population-health approach include
– Communities and governments
– Schools
– Health payors, including
• Employers
• Insurers
• Insurers and employers are emerging as driving forces in
population health response.
Health Plans: Promising Practices
– Provider incentives
– Nutritional counseling
– Physical activity goals
– Patient-customized intervention
– Community education and planning
– Collaborations with employers
• Value-based purchasing
Employers: Diverse Approaches
– Wellness Plans
• Many include support for weight loss
• Diverse supports:
– individualized coaching
» large employers
– discount memberships in commercial weight-loss programs
» feasible for mid-size employers
– Rewarding Healthy Lifestyles
• recognition at department level
• benefits & discounts
Case Study: Chronic Care
Management
• Kaiser-Permanente Health System
– Serves 8.1 million people in 9 states (2005)
– 11,000 physician providers
– Employee population 100,000 +
– National leader, electronic medical records
Case Study: Kaiser Permenente
• Components in chronic care approach:
– Evidence-based clinical practices and weight management
interventions
– Community health initiatives and grants
– Educational theatre programs - health messages to kids
– Farmers’ markets to create healthy food environments in and
around Kaiser Permanente facilities
– Sponsorship of a TV Turnoff campaign to reduce risks
associated with excessive screen time
Histon TM, Goeldner JL, Bachman KH, Rothert K. Kaiser Permanente's disease management approach
to addressing the obesity epidemic. Journal of Clinical Outcomes Management 2005;12(9):464-469.
Promising Research Directions
• Studies of synthesized approaches: clinical intervention,
chronic care management and population health
• New generation of cost-effectiveness studies to develop
evidence-base for payer support
• Long-term studies that yield genuine evidence relevant
to successful management of obesity over the life course
Continuing Research: Phase 2
•
Continuing collaboration with
DMAA: The Care Continuum Alliance
– Independent academic research, employing best
practices
– Dissemination will include creation of information
products to integrate with actionable tools for
employers, insurers, policymakers
Continuing Research: Phase 2
• Focus on population health perspective
1. Case-series study, qualitative exploration of
workplace initiatives
2. Population-health literature review
3. Prototype algorithm derived from evidence-based
guidelines, for integration with DMAA benefit design
for obesity management
Contact information:
Neil Goldfarb, Associate Dean for Research
Jefferson School of Population Health
[email protected]
(215) 955-0247