Medicare May Need to Expand Options for Behavioral
Weight Loss Counseling
Broader range of health professionals needed provide
weight loss counseling for senior citizens, others in Medicare
7, 2014 - An important addition to the “eat less, move more” strategy
for weight loss lies in behavioral counseling to help achieve these
goals. But research on how primary care practitioners can best provide
behavioral weight loss counseling to obese Medicare patients in their
practices - as encouraged by the Centers for Medicare and Medicaid
Services (CMS) - remains slim.
“After an exhaustive search, we found only 12 high
quality randomized controlled trials that examined the behavioral
treatment of obesity in patients encountered in primary care settings,”
said Thomas A. Wadden, PhD, director of Penn’s Center for Weight and
Eating Disorders and the review’s lead author.
“Of those, only two studies identified counseling
interventions that produced an average loss of at least five percent of
initial body weight, an amount likely to improve weight-related health
The researchers initiated their review in response
to two important policy developments in weight management.
>> In 2003 (and
again in 2012), the U.S. Preventive Services Task Force recommended that
primary care practitioners screen all adults for obesity and offer or
refer affected individuals to an intensive, multicomponent weight loss
intervention (typically aimed at modifying diet, physical activity and
related behaviors) .
>> In 2011, CMS
approved payment for intensive behavioral weight loss counseling,
consisting of approximately 14 face-to-face, 10 to 15 minute sessions
over six months, for obese individuals treated in primary care settings.
“The CMS’s decision to reimburse the cost of
intensive behavioral counseling for Medicare-eligible patients was an
important step in advancing the treatment of a disease that has long
been overlooked,” said Adam Tsai, MD, a co-author of the review and an
internal medicine and obesity specialist at Kaiser Permanente in Denver.
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The researchers did not, however, find any studies
in which primary care practitioners delivered behavioral counseling
following the exact CMS guidelines.
Among other requirements, these guidelines specify
that behavioral weight loss counseling must be provided by CMS-defined
practitioners, who currently are limited to physicians, nurse
practitioners, clinical nurse specialists and physician assistants.
Counseling potentially may be provided by auxiliary
health professionals, such as registered dietitians, who work in the
same physical setting as the primary care practitioners and are directly
supervised by them. However, no such studies were identified in the
review. Auxiliary health providers cannot provide weight loss counseling
independently of primary care providers under current CMS guidelines.
The review, which included a total of 3,893
participants, found that behavioral counseling interventions that
included both a reduced-calorie diet (to decrease intake by 500 or more
calories per day) and a program of physical activity (at least 150
minutes or more per week of walking or similar behavior) generally
produced greater weight loss than programs that did not include both of
these specific diet and physical activity prescriptions.
This finding is consistent with recommendations for
comprehensive behavioral weight loss counseling provided by the
Guidelines for the Management of Overweight and Obesity in Adults,
issued jointly in 2013 by the American Heart Association, the American
College of Cardiology and the Obesity Society.
The provision of more counseling visits during the
first six months (for example, 15 sessions versus eight) also tended to
be associated with greater weight loss, “although, we did not identify
enough studies of similar design to formally test this relationship,”
said Meghan Butryn, PhD, a study co-author and associate professor of
psychology at Drexel University in Philadelphia.
“However, previous analyses of weight loss
interventions conducted in academic centers, rather than in primary care
settings, have found that more counseling sessions are associated with
greater weight loss.”
In the study that perhaps came closest to meeting
the CMS requirements, a registered dietitian and an exercise specialist
jointly provided 12 weekly, face-to-face group counseling sessions,
followed by twice monthly telephone or e-mail contacts, to overweight
and obese patients in a large primary practice. Participants lost an
average of 15 pounds in six months, and nearly two-thirds lost five
percent or more of their initial weight.
“These are impressive results for the number of
treatment visits provided, and weight losses were well maintained over
two years,” said Wadden.
Additional studies reviewed by the authors examined
the use as interventionists of medical assistants, community health
educators, and individuals with other professional backgrounds, all of
whom were trained to deliver behavioral counseling. The authors
concluded that further research is needed to evaluate the effectiveness
and cost of having behavioral counseling delivered by CMS-designated
primary care practitioners, as compared with registered dietitians,
nurses, health counselors, and other auxiliary health professionals.
In addition, recent randomized controlled trials,
including one included in the review, have shown that trained
interventionists can effectively deliver weight loss counseling by
telephone and/or Internet. “I think we will see increasing use of
remotely-delivered weight loss counseling, whether by telephone, smart
phones, the Internet or other digital approaches,” Tsai said.
“Telephone-delivered counseling, provided by
counselors from a patient’s primary care practice, or by a trained
interventionist from a disease management call center, is likely to be
more convenient and less costly for patients and potentially for health
care providers and insurers.”
The researchers concluded that physicians and other
primary care practitioners could readily learn to provide intensive
behavioral counseling, like the other trained interventionists
identified in the review. However, ever-increasing demands on
practitioners’ time may favor their referring patients for behavioral
weight loss counseling rather than trying to provide such care
themselves, an option included by the U.S. Preventive Services Task
“A variety of trained interventions potentially
could deliver effective, evidence-based weight loss counseling to the
millions of Americans who would benefit from it, said Wadden. “Primary
care practitioners cannot be expected to go it alone in reducing our
Notes: The other Penn co-author on the paper was Patricia Hong, BS,
a former research coordinator at Penn’s Center for Weight and Eating
Disorders. Wadden’s work on this study was supported, in part, by a
grant from the National Institute of Diabetes and Digestive and Kidney
serves on advisory boards for Nutrisystem, Novo Nordisk, Orexigen and
Shire Pharmaceuticals; he has received grant support, on behalf of the
University of Pennsylvania, from the first three organizations and from
Weight Watchers International. He also serves on an external advisory
board for Johns Hopkins University concerning a proprietary weight loss
program (Innergy), developed by Johns Hopkins University and Healthways.
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