The Evidence Base for Effectiveness of Obesity Management Programs:

A Comprehensive Review of the Literature

Neil GoldfarbAssociate Dean for Research

Joseph Yaskin, M.S.S.Project Manager

Richard Toner, M.S.Research Assistant

Jefferson School of Population HealthPhiladelphia, 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.)

0

10

20

30

40

50

60

70

1976-80

1988-94

1999-2002

2003-2004

2005-2006

Obese

Overweightand Obese

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.

No Significant Change from 20042

1998

Obesity Trends Among U.S. AdultsCDC (BRFSS, 1990, 1998, 2007)

(*BMI 30, or about 30 lbs. overweight for 5’4” person)

2007

1990

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.

• Exercise

• Self-help

• Counseling

• Diet

• Combination of above

Behavioral Interventions

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.

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)

Results: Pharmacologic Studies

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

neil.goldfarb@jefferson.edu

(215) 955-0247