Screening and Treatment
AHRQ-Supported Research Projects
A primary care intervention for obesity.
The goal of this completed study was to improve health professionals' recognition and management of obesity. The project involved implementation of a multifaceted intervention combining academic detailing, information technology, and organizational development.
The impact of the intervention was evaluated by measuring before and after changes in the prevalence of obesity diagnoses and physician screening for BMI as recorded in medical charts of a sample of adult and pediatric patients. The study was carried out in a practice-based research network of community health centers staffed by 88 physicians and 42 mid-level practitioners who are safety-net providers for over 80,000 uninsured and Medicaid managed care patients.
Everett Logue, PI; Summa Health System, Akron, OH. AHRQ grant HS08803, project period 5/1/98-4/30/03.
Building the Alabama practice-based research network.
This completed project involved infrastructure development and research translation using personal digital assistants (PDAs). One component of the project involved a pilot feasibility study on obesity, using PDAs to gather data that could serve as the basis for a larger study aimed at improving patient care and reducing illness and deaths related to obesity.
T.M. Harrington, PI; University of Alabama at Birmingham. AHRQ grant HS13529, project period 9/30/02-9/29/05.
Practice-based research network development and utilization of PDAs in research.
This completed project involved infrastructure development of a practice-based research network comprising 22 practice sites in 18 counties in Georgia and one practice in South Carolina. The practices serve a patient population that is largely poor and rural and more than one-third African American.
In this project, researchers tested the effectiveness of a handheld computer communication system to increase the translation of research evidence into practice in the area of obesity management. Physicians, practicing at randomly assigned intervention or control sites, received obesity treatment updates either to their PDAs or via traditional E-mail only (control). Transmitted information included current guidelines and new findings in obesity treatment.
Peggy Wagner, PI; Medical College of Georgia, Augusta, GA. AHRQ grant HS13513, project period 9/30/02-9/29/05
APRNet: Enhancements and pilot work.
This completed developmental/exploratory grant was focused on enhancing the capacity of APRNet, the first practice-based research network for advanced practice nurses. One of the objectives was to conduct a pilot/feasibility study on the translation of research findings on management of obesity to primary care practice. Goals included:
- Assessing knowledge and attitudes within the network about overweight and obesity identification, evaluation, and treatment.
- Developing and pilot testing an intervention protocol to enhance primary care management of obesity.
Margaret Grey, PI; Yale School of Nursing, New Haven, CT. AHRQ grant HS13493, project period 9/30/02-9/29/04.
Several popular diets confer similar benefits, with best results from strict adherence.
Findings from this study challenge the idea that one type of diet works for everybody, and that low-carb diets work better than standard diets. The study showed that several popular diets resulted in similar weight loss and reduction of several cardiac risk factors over a 1-year period. Dietary adherence, not type of diet, was the key to success, according to the researchers. They randomized 160 adults aged 22 to 72 years to one of four popular diets: Weight Watchers®, the Atkins Diet®, the Zone diet, and the Ornish diet.
All of the subjects were overweight or obese and had several risk factors for cardiac problems (e.g., high blood pressure). Participants were more likely to drop out of the study with the more extreme diets (Atkins and Ornish) than with the moderate diets (Zone and Weight Watchers®). Among those who completed the study, mean weight loss at 1 year was 4.6 lbs for Atkins, 7 lbs for Zone, 6.6 lbs for Weight Watchers®, and 7.3 lbs for Ornish.
Dansinger, Gleason, Griffith, et al., JAMA 2005;293(1):43-53 (AHRQ grant T32 HS00060).
Patients at risk for cardiovascular disease should be counseled about diet and exercise during outpatient visits.
A growing number of Americans have conditions that increase their risk for heart attack and stroke. These include high cholesterol, high blood pressure, diabetes, and obesity. Despite national recommendations to counsel such patients about diet and exercise to reduce their risk, counseling remains suboptimal according to this study.
The researchers found that throughout the 1990s, clinicians provided diet counseling in less than 45 percent of office visits and physical activity counseling in 30 percent or fewer visits by adults with conditions that place them at increased risk for cardiovascular disease. Visits to internists and cardiologists were more likely to include diet and physical activity counseling than visits to general and family physicians. Obese patients and those with hyperlipidemia were much more likely than other patients to be counseled about diet and physical activity. On the other hand, a positive diagnosis of coronary heart disease was not associated with any discernible effect on the likelihood of either type of counseling.
Ma, Urizar, Alehegn, Stafford, Prev Med 2004;39:815-22 (AHRQ grant HS11313).
Studies examine rates of morbid obesity and bariatric surgery and risk of death after surgery.
Bariatric surgery reduces the size of a person's stomach to a tiny pouch, usually bypassing the small intestine. The majority of patients lose 50 to 75 percent of their body weight within 2 years and keep it off. It is the most effective therapy for certain patients with morbid obesity, yet from 0.5 to 1.5 percent of patients die in the hospital after the operation.
In the first study, researchers examined regional differences in morbid obesity and bariatric surgery rates, as well as risk factors for death after surgery. They identified nearly 70,000 patients who underwent the surgery in 2002 and found that the rate of morbid obesity was lowest in the Northeast and West and highest in the Midwest and South. However, the rates of bariatric surgery per 100,000 morbidly obese individuals ranged from a low of 139 in men aged 60 and older in the Midwest to a high of 5,156 in women aged 40 to 49 in the Northeast.
In the second study, researchers identified nearly 55,000 adults who underwent bariatric surgery in 2001 and found that being male, older than age 39, insured through Medicare, or needing additional surgery during the initial hospitalization are factors that increase the risk of postoperative death.
Poulose, Holzman, Zhu, et al., J Am Coll Surg 2005;201:77-84. See also: Poulose, Griffin, Moore, et al., J Surg Res 2005;127:1-7 (AHRQ grant T32 HS13833).
Minimal intervention found to be no more effective than augmented usual care to change behavior among obese patients.
The hypothesis for this study was that after 2 years of treatment, obese patients exposed to an obesity intervention would experience a greater decrease in body weight compared with similar patients who received augmented usual care. The study involved 336 patients. Those in the augmented usual care group received dietary and exercise advice, prescriptions, and three 24-hour dietary recalls every 6 months.
Patients in the intervention group received the augmented care elements, plus "stage of change" assessments for five target behaviors every other month, mailed workbooks, and monthly telephone calls from a weight-loss advisor. The researchers found that the intervention was not powerful enough relative to augmented usual care to alter target behaviors among overweight and obese primary care patients.
Logue, Sutton, Jarjoura, et al., Obes Res 2005;13(5):917-27 (AHRQ grant HS08803).
Clinician's aid focuses on managing obesity.
Incorporating evidence-based approaches to reducing obesity—including screening; counseling; medication; and surgery, when appropriate—may be effective in managing obesity. In 2004, AHRQ published a clinician's aid on managing obesity that highlights research from the Agency's evidence-based practice program. This research informs many science-based recommendations in the public and private sectors, including the U.S. Preventive Services Task Force. This tool provides recommendations for clinicians on screening, counseling, referring, and treating obesity.
Copies of Managing Obesity: A Clinician's Aid (AHRQ Publication No. 04-0082) are available from AHRQ.*
Sibutramine can help manage obesity but may not be appropriate for certain patients.
Clinical trials of sibutramine—a medication that has been approved for long-term management of obesity—in obese individuals have demonstrated significant weight loss and better weight maintenance than placebo. Sibutramine helps weight loss by increasing feelings of fullness and satisfaction. The drug has established general safety and efficacy in long-term trials. However, because the drug increases heart rate and blood pressure, it may be not be appropriate for use in obese patients with significant cardiovascular disease or uncontrolled hypertension. Also, its appropriateness for use in special populations, such as people with binge eating disorders, has not been established.
Poston, Foreyt, Expert Opin Pharmacother 2004;5(3):633-42 (AHRQ grant HS11282).
AHRQ evidence report reviews the science on pharmacologic and surgical treatment of obesity.
In July 2004, AHRQ published a summary of an evidence report prepared for the Agency by the Southern California-RAND Evidence-based Practice Center. In the summary, the researchers assess the efficacy and safety of various weight loss medications and surgical procedures as reported in the scientific literature. They found no evidence that any particular drug promotes more weight loss than another drug. They note that weight loss attributed to pharmacologic treatment is modest but still may be significant. Also, they found that surgical treatment is more effective than nonsurgical treatment for weight loss and control of some coexisting illnesses. Although surgical treatment was found to be associated with a substantial number of complications and adverse events, most of these were minor.
Copies of Pharmacological and Surgical Treatment of Obesity, Evidence Report/Technology Assessment No. 103 (AHRQ Publication Nos. 04-E028-1 [summary], and 04-E028-2 [full report]) are available from AHRQ (contract 290-02-0003).*
Exercise may not mitigate the weight gain of late middle age.
In this study, both men and women aged 51 to 61 in all ethnic groups gained weight from 1992 to 2000, and their current levels of physical activity did not appear to protect against weight gain. The researchers analyzed activity level and changes in weight and BMI over the 8-year study period of 7,391 ethnically diverse community-dwelling adults.
The mean weight gain was higher for women (3.67 pounds) than for men (3.15 pounds). White men and women had the lowest baseline BMI but tended to gain more weight than individuals from other racial groups. After controlling for other factors, those who were older or had higher baseline weight showed less weight gain. Men who reported poor health at baseline were less likely to gain weight than those who reported excellent health. Race, education, and income were not associated with weight gain. Also, regular light or vigorous recreational activities, household chores, or work-related activities were not associated with less weight gain. The authors conclude that high-frequency, moderate-intensity exercise is needed for weight loss.
He, Baker, Am J Prev Med 2004;27(1):8-15 (AHRQ grant HS10283).
Primary care physicians see a substantial portion of the obese population but often do not counsel patients to lose weight.
Researchers examined reports of outpatient visits to study patterns of physician-patient communication around weight control. The reports covered 633 encounters in family practices in a Midwestern State.
They found that 68 percent of adults and 35 percent of children were overweight. Excess weight was mentioned in 17 percent of encounters with overweight patients, while weight loss counseling occurred with 11 percent of overweight adults and 8 percent of overweight children. During weight loss counseling, patients formulated weight as a problem by making it a reason for a visit or asking for help with weight loss. Clinicians framed weight as a medical problem in itself or as an exacerbating factor for another medical problem.
The researchers concluded that strategies to increase the likelihood of patients identifying weight as a problem and strategies that provide clinicians with a way to "medicalize" the patient's obesity are likely to increase the frequency of weight loss counseling in primary care visits.
Scott, Cohen, DiCicco-Bloom, et al., Prev Med 2004;38(6):819-27 (AHRQ grants HS08776 and HS09788).
Researchers examine the relationship over time between elapsed time and the stages of change for weight loss behaviors.
This study involved 329 middle-aged men and women with elevated BMI recruited from 15 primary care practices in Northeastern Ohio. The target behaviors examined were increased planned exercise and usual physical activity, decreased dietary fat, increased fruit and vegetable consumption, and increased dietary portion control. The main outcomes were weight loss (5 percent or more) or weight gain (5 percent or more) after 18 or 24 months of followup.
The researchers found significant longitudinal relationships between weight loss (or gain) and the time in action or maintenance for each of the five target behaviors. They note that the remaining challenge is to identify those factors that reliably move patients into the action and maintenance stages for long periods.
Logue, Jarjoura, Sutton, et al., Obes Res 2004;12:1499-1508 (AHRQ grant HS08803).
Task Force recommends that clinicians screen adults for obesity.
In December 2003, the U.S. Preventive Services Task Force issued their recommendation that clinicians screen all adults for obesity. They also recommended that clinicians offer obese patients intensive counseling and behavioral interventions to promote sustained weight loss or refer them to other clinicians for these services.
The Task Force also noted that clinicians should consider measuring patients for centrally located body weight, which is independently associated with cardiovascular disease, using waist circumference as a measure. Men with a waist circumference greater than 40 inches and women with a waist circumference greater than 35 inches are at increased risk for cardiovascular disease. The Task Force noted, however, that these measurements may be inaccurate for people with a BMI greater than 35.
McTigue, Harris, Hemphill, et al., Ann Int Med 2003;139(11):933-49. See also: U.S. Preventive Services Task Force, Ann Int Med 2003;139(11):930-2; and Summaries for patients, Ann Int Med 2003;139(11):157. To access Task Force recommendations and related materials on the AHRQ Web site, go to http://www.ahrq.gov/clinic/prevenix.htm.
Weight goals for younger people may not be appropriate for elderly people.
According to this study, extra weight may be protective for the elderly. The researchers found that obese elderly people were less likely to die than those who were thin or normal weight, even after adjusting for differences in medical problems and income.
They analyzed data from a nationally representative sample of 7,527 community-dwelling adults aged 70 and older in 1984 to calculate the impact of BMI on their risk of death over an 8-year period. Subjects were divided into three groups: thin (BMI less than 19), normal weight (BMI 20-28), and obese (BMI 29 or greater). The thin group had the highest mortality rate (54 percent), the obese group the lowest (33 percent), and normal-weight individuals were in the middle (37 percent).
Grabowski, Ellis, J Am Geriatr Soc 2001;49:968-79 (AHRQ grant T32 HS00084).
A patient's willingness to make dietary and lifestyle changes is key to sustained weight loss.
This study found that most patients are receptive to losing weight under their doctor's supervision, but that patients vary in their readiness to adopt specific weight-loss behaviors. For instance, some patients may be ready to increase their exercise but not to reduce the fat in their diet. Others may be ready to eat more fruits and vegetables but not to eat smaller portions of food.
The researchers administered questionnaires to 284 obese family practice patients to examine their receptivity (stage of change) to six target behaviors: dietary fat, portion control, vegetable intake, fruit intake, usual physical activity, and planned exercise. The resulting profiles indicate which behavior(s) a patient is ready to work on at any given clinical visit and can be used by doctors to help their patients lose weight over time.
Logue, Sutton, Jarjoura, Smucker, J Am Board Family Pract 2000;13:164-71 (AHRQ grant HS08803).
Specific interventions to address obesity are infrequent in visits to U.S. physicians.
For this study, researchers analyzed more than 55,800 adult physician office visits sampled in the 1995-1996 National Ambulatory Medical Care Surveys to assess reporting of obesity during office visits and physician counseling for weight loss, exercise, and diet among patients identified as obese. They found that physicians reported obesity in only 8.6 percent of visits.
Among visits by patients identified as obese, physicians frequently provided counseling for weight loss, exercise, and diet. However, each service was provided to no more than one-quarter of all obese patients. Patients with obesity-related illnesses were treated more aggressively, yet weight loss counseling occurred at only 52 percent of the visits.
Stafford, Farhat, Misra, Schoenfeld, Arch Fam Med 2000;9(7):631-8 (AHRQ grant HS07892).
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Overweight in Children and Adolescents
AHRQ-Supported Research Projects
Treatment of children with overweight in primary care.
This current project is applying concepts from the chronic care model to the problem of pediatric overweight. Researchers are assessing the effectiveness of teaching primary care providers to use specific communication strategies with parents of overweight children to help them take steps with their child toward healthy behavior change. Second, they are offering core components of a family-based behavioral weight management program within the pediatric primary care setting to determine if participating children will achieve clinically meaningful weight loss. Third, they are assessing the ability of trained, practice-based staff members to offer the treatment so that desired outcomes are achieved.
The three principal outcomes are:
- A change in the frequency with which providers counsel parents of overweight children.
- A change in the child's diet, physical activity, weight, and BMI percentiles after treatment and at 6-month followup.
- A comparison of child outcomes in groups led by trained staff compared with those in groups led by experienced interventionists.
Ellen Wald, PI; Children's Hospital, Pittsburgh, PA. AHRQ grant HS14862, project period 11/1/05-10/31/07.
Improving overweight care in pediatric offices.
The goal of this current project is to improve communication about childhood and adolescent overweight in the offices of pediatricians.
The project has four objectives:
- Describe the current frequency of evaluation by pediatricians of obesity in children ages 6 to 17.
- Assess the experiences and attitudes of pediatricians in diagnosing and discussing overweight, particularly the interpersonal barriers to labeling a child as overweight.
- Assess experiences and attitudes of adolescents and parents of younger children in discussing overweight with the pediatrician to learn which approaches are acceptable, as well as those that either alienate or motivate them.
- Test the effect on pediatricians' self-efficacy of an intervention that teaches them how to address overweight to create an alliance with parents and families and motivate them to make changes.
Analysis of interviews and focus groups will assist in developing the content of an educational program that will be assessed in pre- and post-testing of pediatricians.
Sarah Barlow, PI; St. Louis University, St. Louis, MO. AHRQ grant HS13901, project period 9/1/03-8/31/08.
Tools to improve nutritional health in primary care.
The goal of this completed pilot study was to test the implementation of a program to assist health providers in the interpretation of child growth and the routine delivery of nutritional counseling in two pediatric practices. One practice served a majority of white, privately insured patients; the other was a community health center serving low-income African American and Hispanic patients.
The goal was to allow practices to more easily include routine growth interpretation and child-specific counseling on healthy behaviors, thus increasing the motivation of physicians to address this key area.
Adolfo Ariza, PI; Children's Memorial Hospital of Chicago, Chicago, IL. AHRQ grant HS14431, project period 9/30/03-12/31/05.
DVDs help parents and clinicians address overweight in children.
In 2004, AHRQ and Discovery Networks, Inc., worked in partnership to develop two DVDs—Max's Magical Delivery: Fit for Kids and Childhood Obesity: Combating the Epidemic—in response to the growing problem of childhood overweight in the United States.
Max's Magical Delivery is a fun, interactive DVD targeted to children ages 5-9 and their families. The DVD offers suggestions on daily diet, use of TVs and video games; and physical activity. There is a separate section for parents on small, achievable steps they can take to encourage healthy habits in their children and themselves.
Childhood Obesity is a complementary DVD targeted to clinicians. It addresses both prevention and treatment, including screening and counseling of children who are overweight or at risk for overweight. It provides helpful clinical tools such as BMI measurement in children and tips for initiating and sustaining behavior change in children. This DVD contains educational materials eligible for CME and CE credits that can be obtained through the Centers for Disease control and Prevention (CDC).
Copies of Max's Magical Delivery (AHRQ Publication No. 04-0088-DVD) and Childhood Obesity (AHRQ Publication No. 04-0089-DVD) are available from AHRQ.*
Task Force examines evidence on screening for overweight in children and adolescents.
In July 2005, the U.S. Preventive Services Task Force issued their recommendation on screening children and adolescents for overweight. The Task Force recognized childhood overweight as an important public health issue, and they noted that it is important to measure and monitor growth over time in all children and adolescents. However, they did not find enough evidence to show that routine screening for overweight will identify children who are at risk for future adverse health outcomes, such as cardiovascular disease.
This finding by the Task Force of "insufficient evidence" (an "I" recommendation) is a call to action for the research community to focus future research efforts on addressing gaps in the evidence on child and adolescent overweight.
Published online at www.pediatrics.org/cgi/content/full/116/1/e125. Also, visit the AHRQ Web site at http://www.ahrq.gov/clinic/prevenix.htm for more information about this and other Task Force recommendations.
Clinicians are more likely to counsel youngsters who have been diagnosed as overweight.
According to this study, when overweight is diagnosed in children aged 2 to 18, clinicians are more likely to counsel them and their parents about diet and exercise during well-child visits. Based on an analysis of 1997-2000 survey data, the researchers found that clinicians diagnosed overweight at less than 1 percent of 39,930 ambulatory pediatric visits. When patients were diagnosed as being overweight at well-child visits, clinicians assessed their blood pressure and counseled them about diet and exercise more often than they did for patients at visits where overweight was not diagnosed.
Factors associated with diet counseling were diagnosis of overweight, being seen by a pediatrician, aged 2 to 5 years compared with 12 to 18 years, and self-pay compared with private insurance. Factors were similar for exercise counseling, except exercise counseling occurred half as often in visits with black youths compared with visits with white youths.
Cook, Weitzman, Auinger, Barlow, Pediatrics 2005;116(1):112-6 (AHRQ grant HS13901).
Dietary control and physical activity can help overweight children lose weight.
Excess weight in children and adolescents is due primarily to poor eating habits and inactivity, according to these researchers. They recommend that children eat at least five servings of fruits and vegetables each day, engage in moderate physical activity for at least 60 minutes on most days, and limit their TV viewing and computer use to no more than 2 hours a day.
Parents and clinicians should strive first to maintain a child's baseline weight. Weight loss of no more than 1 pound per month is recommended in children aged 2 to 7 who have a secondary weight-related complication such as high blood pressure. Weight loss should be considered for children aged 7 and older if their BMI for age is 95 percent or greater, or they are at risk for becoming overweight (BMI for age of 85 to 95 percent) and they have secondary complications.
Greaser, Whyte, Consultant, online at www.consultantlive.com, 2004. Reprints (AHRQ Publication No. 05-R011) are available from AHRQ (Intramural).*
Late bottle weaning is associated with an increased risk of overweight.
The American Academy of Pediatrics recommends introducing babies to the cup at 6 months and complete bottle weaning at 15 months of age. Yet 20 percent of toddlers aged 2 and 9 percent of those aged 3 are still using a bottle. Prolonged bottle use in young children is associated with increased risk of overweight, according to this study. Compared with normal-weight infants, overweight infants are more likely to be overweight in the preschool years and are at increased risk of obesity in later life.
This study involved survey results for a sample of nearly 3,000 children aged 3 to 5 years. The mean age of bottle weaning was 18.8 months. Children less than the 85th percentile BMI (normal weight) were weaned at an average of 18 months, compared with 19 months for those in the 85-95th percentile BMI (overweight) and more than 22 months for children greater than the 95th percentile BMI (obese). Each additional month of bottle use corresponded to an approximate 3 percent increase in the odds of being in a higher BMI category.
Bonuck, Kahn, Schechter, Clin Pediatr 2004;43:535-40 (AHRQ grant HS10900).
Prolonged bottle feeding of young children may lead to childhood obesity and iron deficiency anemia.
The authors of this study warn that prolonged and/or excessive bottle use may increase a young child's risk of developing iron deficiency anemia or becoming overweight. Researchers surveyed caregivers of 95 children aged 18-56 months (most children were Hispanic or black) about bottle use.
Half of the children were overweight, 36 percent were obese, and 21 percent met CDC criteria for anemia. Two-thirds of the children received daily bottles of milk or sweet liquids, with children receiving anywhere from 3 to 10 bottles a day. Bottle use was significantly associated with anemia and obesity but not with overweight.
Bonuck, Kahn, Clin Pediatr 2002;41:603-7 (AHRQ grant HS10900).
Minority youths are more likely than white youths to be overweight.
According to this study, African-American and Hispanic children aged 6 to 11 in the United States are significantly more likely than non-Hispanic white children of the same age to be overweight, while Asian and Pacific Islander children are slightly less likely to be overweight.
Using data from AHRQ's 1996 MEPS, the researchers found that 43.9 percent of the African-American children were overweight, as were 37.4 percent of Hispanic children. The researchers also found that 21.1 percent of non-Hispanic white children and 19.6 percent of Asian and Pacific Islander children had excess weight.
Haas, Lee, Kaplan, et al., Am J Public Health 2003;93(12):2105-10 (AHRQ grant HS10856).
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Expert panel meeting focused on safety issues in bariatric surgery.
Although the demand for and use of bariatric surgery are growing, there is little information on long-term outcomes and safety-related issues, including data on variations in outcomes related to surgical site and expertise/experience of the surgeon.
In October 2004, AHRQ convened an expert panel meeting focused on bariatric surgery. The meeting involved a roundtable of experts in bariatric surgery and other key stakeholders who examined what is known about the safety of these surgical procedures, the need for additional safety data, and options for meeting data needs.
2005 conference highlights efforts to eliminate obesity and health disparities.
In July 2005, AHRQ and the National Cancer Institute cosponsored the third annual Translating Research Into Practice (TRIP) conference, which was held in Washington, DC. The conference theme was "Highlighting Obesity and Health Disparities Reduction." Presenters shared innovative research and implementation methods, case studies, and other experiences.
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AHRQ Publication No. 06-P012
Current as of April 2006
Research on Obesity and Overweight—AHRQ-Supported Research and Recent Findings. Program Brief. AHRQ Publication No. 06-P012, April 2006. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/obesity.htm