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 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 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 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. 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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.