Sunday, March 16, 2008

JAMA Article about Obesity Disease Management

The publication of the Weight Loss Maintenance (WLM) trial in JAMA caught the attention of the Disease Management Care Blog. It’s one thing for patients to achieve weight loss. It’s another for that weight loss to be maintained.

The WLM trial is worth a close read because it a) rigorously tested state-of-the-art weight maintenance approaches that are typically used in disease management programs and b) provided an usually long period of follow-up.

The full study is available on line here. As a service to readers of the DMCB, I've provided a summary. To skip forward to lessons for the disease management community, scroll down to the bold text below.

In order to qualify for inclusion, persons had to have a BMI between 25 and 45 and have either high blood pressure or high blood cholesterol (heart disease and diabetes patients were excluded). Participants then went through 6 months of weekly group sessions consisting of diet (‘Approaches to Stop Hypertension’) and exercise advice. Persons who had lost at least 4 kilograms (about 9 lbs.) were then randomly assigned to one of three types of weight maintenance follow-up over 30 months: 1) personal contact (monthly 10-15 minute phone calls), 2) interactive technology (consisting of a personalized password protected web site) or self-directed care (some printed materials and goodbye). The study centers were Duke, Johns Hopkins, Pennington Biomedical Research Center and Kaiser Permanente.

The average starting BMI in the study participants was a generous 34.1. 1685 persons started the trial and 1032 (61%) managed to lose the approximately 9 or more lbs to qualify for the rest of study. The average weight loss was over those 6 months was 8.5 kg (18.7 lbs).

Over the 30 months of the study, the persons assigned to the personal contact did better than the web site or self care. Weight regain was 5.5 kg. (12 lbs) in the self directed group, 5.2 kg. (11.4 lbs) in the web-based group and 4 kg. (9 lbs) in the personal contact group. In other words, the personal contact patients avoided an average of 3.3 lbs weight gain. 42% in the personal contact group vs. 35% and 34% in the web site and self directed groups respectively stayed at least 5% below the entry weight. The impact on the programs on blood pressure and blood cholesterol went unreported.

Kudos to the authors for gauging the success of this program among a group of persons with special health care needs: African Americans. The subgroup analysis for these individuals revealed their program results were no different.

What are the lessons for the disease management organizations that offer weight loss programs?

First off, this study could have been titled “A study on the value of two already widely used disease management strategies vs. usual care for sustaining weight loss.” The researchers in this study saluted themselves for establishing the value of an “efficient and practical mode of delivery” but failed to mention that the personal contact phone call is in already place and available to millions of commercially insured persons who have access to disease management programs.

Personalized phone calls appear to work better than web-based interventions. I tried to get into the WLS web site to take it for a test drive but was unable to do so. It may or may not be as “rich” as commercially based programs’ web sites, which are constantly being updated and modified. Nonetheless, this is consistent with what disease management programs have known all along: high touch beats high tech. In other words, purchasers of disease management programs aka weight loss/maintenance programs get what they pay for.

Since the industry is constantly improving their web-based approaches to patient care, it’s hard to know if all commercially available web-based approaches to weight loss maintenance can be painted with the same WLS brush. In the estimation of the DMCB, that misses the point. In any population, there are persons who prefer web-based approaches. Persons with such a preference may be very successful in maintaining weight loss. That was not evaluated in this study. In addition, both web-based approaches and telephoney probably work better than either alone.

The disease management industry has a useful benchmark. Personalized weight maintenance follow-up can be expected to result in keeping about 10 lbs off among persons who initially lose 20 lbs.

National guidelines on the topic of weight loss recommend that one measure of the success of weight loss among persons with obesity is 10% of body weight. Using that very hard-to-reach threshold, this study was a complete failure. It’s depressing isn’t it? After all that time and trouble and state of the art treatment, persons with a BMI in the 30s lost about 10 lbs over the 2-3 years of the study. Reality check!

Last but not least, it appears that physicians were not involved. This may strike some as a threat to the profession, but a) physicians are typically not well trained in ongoing counseling for weight loss maintenance and b) the DMCB doesn’t think most primary care physicians are very interested in that kind of work anyway. That being said, it’s notable that the authors failed to note that one stumbling block to this “efficient and practical mode of delivery” may be a lack of physician buy-in in many usual care settings. The disease management industry knows this very well, but probably finds it ironic that this study was published in this journal named for the parent organization: the American Medical Association.


Yaacov said...

How effective do you think coaching by email on a more regular basis such as weekly/daily versus the short 15 minute phone call would be?

Anonymous said...

Excellent point. My blog post was getting too lengthy and I resisted bringing that up. I agree the monthly phone call seemed minimal follow-up and higher frequency may have yielded better results. My read of the literature makes me think higher frequency/intensity and multiple interventions work better than just one type. And yes, your point about emails is a great insight, making me think of other coaching "channels" like text messaging and interactive voice response. If anyone knows of some good info in this regard, please let the me and other readers know.

Yaacov said...

Paid diet sites are definitely starting to offer text messaging with nutrition info, alerts, etc.

Have you read the Beck Diet Solution?

Anonymous said...

any comments regarding Self insured employer based programs, like P&G using financial incentives such as lower contributions to health care benefits?