Work Group Questions and Readings

Behavioral Interventions

Work Group Questions and Readings

EFFICACY

OPTIMAL TREATMENT DOSE: What is the evidence that the effectiveness of behavioral interventions varies by the number of visits, and length of treatment (the “dose” of behavioral intervention)?What is the evidence that there is a threshold effect (i.e. minimum dose) or a plateau effect?

Readings:

2013 AHA/ACC/TOS guideline for the management of overweight and obesity in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society. Circulation.2013;00:000–000. This article is co-published in the Journal of the American College of Cardiology and Obesity. The following website has the article with the CPG and the complete report:

The AHA/ACC/TOS guideline workgroup addressed the following key question to address the issue of intensity or dose of behavioral intervention:

6.14.. . Characteristics of Lifestyle Intervention Delivery That May Affect Weight Loss: Intervention Intensity

See page 185-188 of the Complete Report, as well as subsequent recommendations, rationale, and research gaps in this section of the complete report. Note that at the time of the publication of the 2013 AHA report there were no randomized controlled trials that directly addressed intervention intensity.

Balk EM, Earley A, Raman G, Avendano EA, Pittas AG, Remington PL.

Combined diet and physical activity promotion programs to prevent type 2 diabetes among persons at increased risk: a systematic review for the Community Preventive Services Task ForceAnn Intern Med 2015;163. doi:10.7326/M15-0452

Wadden TA, Butryn ML, Hong PS, Tsai AG. Behavioral treatment of obesity in patients encountered in primary care settings: a systematic review. JAMA. 2014 Nov 5;312(17):1779-91. doi: 10.1001/jama.2014.14173. Review. PubMed PMID: 25369490; PubMed Central PMCID: PMC4443898.

DESIREABLE BEHAVIORAL INTERVENTIONS: What components or modalities (ways of delivering) of behavioral interventions have proven effective and should be emphasized for behavioral weight management?

In addition to addressing the “dosing” question (Q1), The AHA/ACC/TOS guideline workgroup addressed these following key questions regarding the issues of components and modalities (delivery methods) for behavioral interventions:

6.6..... Diet, Physical Activity, and Behavior Therapy Components in High-Intensity, OnSite Lifestyle Interventions—... 162

6.7..... Comprehensive Interventions Compared with Usual Care, Minimal Care, or No-Treatment Control—... 165

6.8..... Efficacy/Effectiveness of Electronically Delivered, Comprehensive Interventions in Achieving Weight Loss. 170

6.9..... Efficacy/Effectiveness of Comprehensive, Telephone-Delivered Lifestyle Interventions in Achieving Weight Loss. 173

6.10... Efficacy/Effectiveness of Comprehensive Weight Loss Programs in Patients Within A Primary Care Practice Setting Compared With Usual Care

6.12... Efficacy/Effectiveness of Very Low-Calorie Diets, as Used as Part of a Comprehensive Lifestyle Intervention in Achieving Weight Loss—... 178

6.13... Efficacy/Effectiveness of Comprehensive Lifestyle Interventions in Maintaining Lost Weight—... 180

6.15... Characteristics of Lifestyle Intervention Delivery That May Affect Weight Loss or Weight Loss Maintenance: Individual vs. Group Treatment—... 187

6.16... Characteristics of Lifestyle Intervention Delivery That May Affect Weight Loss Or Weight Loss Maintenance: Onsite vs. Electronically Delivered Interventions—... 188

Burke LE, Wang J, Sevick MA. Self-monitoring in weight loss: a systematic review of the literature.J Am Diet Assoc. 2011 Jan;111(1):92-102

Hartmann-Boyce J, Johns DJ, Jebb SA, Aveyard P; Behavioural Weight Management Review Group.Effect of behavioural techniques and delivery mode on effectiveness of weight management: systematic review, meta-analysis and meta-regression. Obes Rev. 2014 Jul;15(7):598-609.

Madigan CD, Daley AJ, Lewis AL, Aveyard P, Jolly K.Is self-weighing an effective tool for weight loss: a systematic literature review and meta-analysis.Int J BehavNutr Phys Act. 2015 Aug 21;12(1):104.

STEPPED-CARE: What is the definition of “failure” to lose weight via behavioral weight management that would make a Veteran eligible/appropriate for weight loss medications or weight loss surgery?

Reading:

Sharma AM and RF Kushner. A proposed clinical staging system for obesity. International Journal of Obesity (2009) 33, 289–295.

VA/DoD 2014 Clinical Practice Guideline for the Screening and Management of Overweight and Obesity, available at:

EFFECTIVENESS/IMPLEMENTATION

DESIREABLE IMPLEMENTATION COMPONENTS: What is the most effective strategy (climate, facilitation roles, etc.) for implementing a standardized behavioral weight management intervention, based on the lessons from the most effective sites?

Reading:

Damschroder LJ, Lowery JC. Evaluation of a large-scale weight management program using the consolidated framework for implementation research (CFIR) Implementation science.Implementation Science. 2013;8:51.

Kahwati, LC, Lewis, MA, Kane, H, et al. Best Practices in the Veterans Health Administration’s MOVE! Weight Management Program Am J Prev Med 2011;41(5):457–464.

BARRIERS & FACILITATORS: What are the barriers and facilitators at the level of the patient, provider, facility, and health system to identification, referral, and sustained engagement of obese patients in behavioral weight management?

Reading:

Armstrong MJ, MottersheadTA, Ronksley PE, et al. Motivational interviewing to improve weight loss in overweight and/or obese patients: a systematic review and meta-analysis of randomized controlled trials. Obesity Reviews (2011) 12, 709–723.

Kahwati, LC, Lewis, MA, Kane, H, et al. Best Practices in the Veterans Health Administration’s MOVE! Weight Management Program Am J Prev Med 2011;41(5):457–464.

REACH: What is the effect of offering a less intensive (though still effective) intervention on reach and overall impact? How does reach (% of Veterans who utilize an intervention) vary by dose of intervention, e.g., minimal effective versus maximal effective dose?

Reading:

Curry SJ, McNellis RJ. Behavioral Counseling in Primary Care: Perspectives in

Enhancing the Evidence Base. Am J Prev Med. 2015 Sep;49(3 Suppl 2):S125-8. doi:

10.1016/j.amepre.2015.06.004. PubMed PMID: 26296546.

OTHER SUGGESTED READINGS:

LeBlanc ES, MD, MPH; Elizabeth O’Connor, PhD; Evelyn P. Whitlock, MD, MPH; Carrie D. Patnode, PhD, MPH; and Tanya Kapka, MD, MPH. Effectiveness of Primary Care–Relevant Treatments for Obesity in Adults: A Systematic Evidence Review for the U.S. Preventive Services Task Force. Ann Intern Med. 2011;155: 434-447

This article by USPSTF is a meta regression most relevant to questions of efficacy and separately synthesizes evidence for trials of behavioral intervention and trials of medications. The investigators found that no component was associated with degree of weight loss. However, more effective higher-intensity interventions usually included self-monitoring, setting goals, addressing barriers to change, and strategizing about maintaining long-term changes. The question of “dose” was also investigated with somewhat different cutoffs than the AHA/ACC/TOS review.

Wadden TA, Webb VL, Moran CH, Bailer BA. Lifestyle modification for obesity: New developments in diet, physical activity, and behavior therapy. Circulation. Mar 6 2012; 125(9):1157-1170

The Wadden review addresses modality of intervention delivery as well as the value of integrating components. It provides a high level overview of the Diabetes Prevention Program, the 13.5 year randomized Look AHEAD (Action for Health in Diabetes) trial, and diets differing in macronutrient content.