0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Original Investigation |

Trial of Prevention and Reduction of Obesity Through Active Living in Clinical Settings:  A Randomized Controlled Trial FREE

Robert Ross, PhD; Miu Lam, PhD; Steven N. Blair, PED; Timothy S. Church, MD, PhD; Marshall Godwin, MD; Stephen B. Hotz, PhD; Ana Johnson, PhD; Peter T. Katzmarzyk, PhD; Lucie Lévesque, PhD; Susan MacDonald, MD
[+] Author Affiliations

Author Affiliations: School of Kinesiology and Health Studies (Drs Ross and Lévesque), Departments of Endocrinology and Metabolism (Dr Ross) and Community Health and Epidemiology (Drs Lam and Johnson), School of Medicine, and Centre for Studies in Primary Care, Department of Family Medicine (Dr MacDonald), Queen's University, Kingston, Ontario, Canada; Departments of Exercise Science and Epidemiology and Biostatistics, University of South Carolina, Columbia (Dr Blair); Pennington Biomedical Research Center, Baton Rouge, Louisiana (Drs Church and Katzmarzyk); Primary Healthcare Research Unit, Memorial University of Newfoundland, St John’s, Newfoundland, Canada (Dr Godwin); and Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Ontario, Canada (Dr Hotz).


Arch Intern Med. 2012;172(5):414-424. doi:10.1001/archinternmed.2011.1972.
Text Size: A A A
Published online

Background The efficacy of physical activity with a healthful diet to reduce obesity is established; however, little is known about the translation of effective lifestyle strategies for obesity reduction in primary care settings.

Methods We assessed the effectiveness of a 2-year behaviorally based physical activity and diet program implemented entirely within clinical practices to reduce obesity. A total of 490 sedentary, obese adults were randomized to usual care (n = 241) or to the behavioral intervention (n = 249). The usual care group received advice from their physicians about lifestyle as a strategy for obesity reduction. The behavioral intervention included individual counseling from health educators to promote physical activity with a healthful diet. The primary outcome was change in waist circumference (WC).

Results A total of 396 participants completed the trial (80.8%). A significant main effect was observed for WC change within the intervention compared with usual care (P < .001) that was sustained at 24 months (mean [SE], −0.9 [0.4] vs 0.2 [0.4] cm; P = .05). Secondary analyses revealed significant main effects for change in WC in men (P = .009) and women (P = .02). In men, the mean (SE) reduction in WC at 24 months was greater with behavioral intervention compared with usual care (−1.6 [0.6] vs 0.1 [0.6] cm; P = .049). In women, the behavioral intervention was associated with differences in WC compared with usual care at 6 and 12 months (P ≤ .01) but not at 24 months (P = .10).

Conclusions Behavioral intervention in clinical settings is associated with modest reductions in WC during a 2-year study in obese patients. However, the effectiveness of the intervention is restricted to men.

Trial Registration clinicaltrials.gov Identifier: NCT00665158

Figures in this Article

Obesity increases the risk of numerous chronic diseases, resulting in a decline in the quality and duration of life.1,2 Despite widespread awareness of the importance of reducing obesity and promoting healthy lifestyles, most primary care clinicians fail to counsel obese patients adequately.3 Commonly cited barriers include limited time, counseling expertise, and staff support and a lack of effective treatments.4,5 These limitations are reinforced by the recommendation that clinicians screen adults for obesity and offer intensive counseling and behavioral interventions for weight management.1,6 The US Preventive Services Task Force recommends intensive counseling (defined as >1 visit per month for 6 months) because evidence does not support the use of low- or moderate-intensity counseling (3-6 visits during 1-2 years) by primary care physicians alone as an effective strategy for achieving weight loss.6,7 The time and expense required for primary care practitioners to provide high-intensity behavioral counseling as recommended is unlikely given the absence of adequate reimbursement and the routine demands of office practice.

We acknowledged these limitations and proposed in response that effective obesity reduction at the primary care level requires that the clinician work in close concert with a specially trained health educator. Insertion of the health educator into the clinical practice would provide these professionals with direct and immediate access to patients and extensive opportunities to interact with physicians and other clinical staff. Inclusion of the health educator as an integral component of the primary care team would optimize the physician's contribution to the intervention and underscore the perceived value of obesity reduction to the patient. The feasibility and/or effectiveness of placing a health educator within the primary care practice to deliver the lifestyle intervention and the willingness of patients to participate in a long-term obesity reduction trial in a clinical setting is unknown.

The Prevention and Reduction of Obesity Through Active Living (PROACTIVE) trial was specifically designed to assess the effectiveness of a 24-month behaviorally based physical activity and diet program aimed at reducing obesity and related metabolic risk factors in abdominally obese adults in primary care settings. We hypothesized that a pragmatic individualized education and behavior counseling program delivered to patients by a health educator would result in a reduction in waist circumference (WC) compared with usual care.

DESIGN

Details of the PROACTIVE trial's design and methods have been published elsewhere.8 PROACTIVE was a 24-month randomized, controlled trial with 2 arms: a usual care control condition and a lifestyle-based behavioral intervention. The study was approved by the Queen's University Faculty of Health Sciences Research Ethics Board. Participants provided written informed consent before participation.

Approximately 36 physicians from 3 family medicine clinics participated in the trial. Physicians supplied their patient list to the project coordinator, who subsequently created an information letter for each participant. Participant flow throughout the trial is illustrated in Figure 1.

Place holder to copy figure label and caption
Graphic Jump Location

Figure 1. Participant flow diagram.

PARTICIPANTS

A total of 10 349 patients received personalized recruitment/information letters from December 1, 2004, through January 31, 2008. In all, 490 sedentary (planned activity ≤1 time/wk), overweight (body mass index [BMI; calculated as weight in kilograms divided by height in meters squared], 27-39), and abdominally obese (WC, ≥102 cm in men or ≥88 cm in women) adults were randomly assigned to the intervention or to the usual care arm. Patients with dyslipidemia, type 2 diabetes mellitus, or hypertension were not excluded from participation. Exclusion criteria included serious medical conditions that prevented participants from increasing daily physical activity.

INTERVENTIONS
Usual Care

Participants randomized to usual care received advice from their physicians regarding lifestyle as a strategy for obesity reduction and continued to meet with their physician according to their usual schedule. Physicians were asked not to change their routine counseling approach for obese PROACTIVE patients.

Behavioral Intervention

Details of the behavioral intervention are published elsewhere.8 The 2-year, multiphase intervention was designed to promote physical activity concurrent with the consumption of a balanced diet. The intervention included individually tailored counseling based on the transtheoretical model and social cognitive theory.911 Counseling was delivered by health educators who had degrees in kinesiology and who received behavioral counseling training from a clinical psychologist. Each health educator was assigned to 1 of 3 family medicine clinics and delivered all counseling sessions on site within a private office. Motivational interviewing served as the counseling model.9 During phase 1 of the intervention (months 0-6, 15 sessions), the health educator worked one on one with participants to provide knowledge and skills to increase daily physical activity and consume a healthful diet. Phase 2 (months 7-12, 6 sessions) started at session 16 and encouraged the participants to maintain their current program (45-60 minutes of activity per day and healthy eating patterns). During phase 3 (months 13-24, 12 sessions), contact with health educators continued, but the session duration was determined according to each participant's WC value and physical activity level.

RANDOMIZATION

Eligible participants were randomized on the basis of a computer-automated randomization sequence after the acquisition of primary outcome data. Randomization was stratified by sex, age, and WC measurement. It was not possible to conceal the group assignment from the patients or the physicians. Strategies to decrease the likelihood of contamination and bias included the following: (1) baseline data were collected before randomization; (2) participants were asked not to disclose their group assignment to measurement staff at subsequent visits; (3) measurements used to determine the presence of the metabolic syndrome included automated blood pressure and laboratory tests (fasting glucose, triglyceride, and high-density lipoprotein cholesterol levels) that are unlikely to be affected by human bias; and (4) physicians were explicitly informed of the importance of not making changes to their usual approach to lifestyle counseling during the study.

Follow-up data collection occurred within a laboratory removed from the participating medical clinics at 6-month intervals after randomization. Primary outcome data and physical activity data based on the 7-day Physical Activity Recall interview12 were obtained at all visits. Information on adverse events and medication use was also obtained by self-report at each visit.

OUTCOME MEASURES

The primary outcome variable was WC measured at the superior edge of the iliac crest.13 Secondary outcomes included common metabolic risk factors, body fat percentage measured using bioelectrical impedance (BCA-418; Tanita Corporation of America, Inc), and the metabolic syndrome identified using the consensus-harmonized definition and a WC threshold of at least 102 cm in men and at least 88 cm in women.14 All metabolic measurements were performed in the morning after an overnight fast using standard procedures.8

SAMPLE SIZE AND STATISTICAL POWER

Sample size and power calculations were computed for WC and the metabolic syndrome. Given that WC is a continuous variable and the metabolic syndrome is a dichotomous variable, the sample size derivation was based on the metabolic syndrome. Assuming an α level of .05, a β level of .20, and a study population metabolic syndrome prevalence of 55%, 174 subjects were required in each study arm to identify a 15% reduction in the metabolic syndrome prevalence. The sample size achieved was 490, including 241 (169 women and 72 men) in the usual care arm and 249 (175 women and 74 men) in the intervention arm. This sample size provided a power of more than 99% to detect a 5% (5.3 cm with an SD of 11 cm) difference in WC and a power of more than 88% to detect a 3% (3.2-cm) difference in WC. For the subset analysis in men, we had a power of more than 82% to detect a 5% (5.3-cm) difference in WC.

STATISTICAL ANALYSIS

Analyses were performed on an intent-to-treat basis.15 All randomized subjects were included. All analyses were performed using commercially available software (SAS, version 9.2; SAS Institute, Inc). An α value of .05 was used to determine statistical significance. Differences in continuous and categorical variables between dropouts and participants who completed the study were examined using a 2-tailed t test and a χ2 test, respectively. For WC, a linear mixed model for repeated measures over time was applied separately for men and women. The model included the following fixed effects: intervention, time, and their 2-factor interactions, with age and medical clinic as covariates. For the metabolic syndrome, a generalized linear mixed model with a logit link was applied using the same modeling approach used for WC. An unstructured covariance matrix was imposed for these models. Estimated within-group changes in WC between baseline and 6 to 24 months were estimated and compared using contrasts within the mixed models. Baseline outcome was further included in the mixed models as a covariate to determine the change in outcome from baseline.

Of the 490 participants, 396 (80.8%) returned for follow-up testing at 24 months. Return for follow-up within the usual care and intervention groups was 85.5% and 76.3%, respectively, and for men and women, 82.9% and 79.9%, respectively (Figure 1). There were no significant baseline differences between participants who completed vs those who dropped out of the trial (data not shown). Adherence to the intervention, defined as the percentage of sessions attended with the health educator, averaged 73.5% (73.4% in men and 73.9% in women) and ranged from 0% (n = 3) to 100% (n = 35); 127 participants attended at least 90% of the expected sessions.

As summarized in Table 1, the mean (SD) age of the participants in the usual care and intervention groups was 52.4 (11.8) and 51.3 (11.0) years, respectively. The mean (SD) WC level in the groups was 105.9 (10.8) and 107.2 (11.0) cm, respectively. Rates of medication use for blood pressure and lipid and glucose levels were not different between groups.

Table Graphic Jump LocationTable 1. Participant Characteristicsa

Table 2 presents the primary outcome measure. A significant main effect was observed for change in WC in response to the intervention compared with usual care (P < .001). The mean reduction in WC was greater in the intervention group than in the usual care group at each follow-up visit and remained statistically different at 24 months (mean [SE], −0.9 [0.4] vs 0.2 [0.4] cm; P = .05). Secondary analyses revealed significant main effects for a change in WC in men (P = .009) and women (P = .02; Table 2). In men, the reduction in WC was greater within the intervention than usual care groups at each follow-up visit and remained statistically different at 24 months (P = .049). In women, the reduction in WC was greater in the intervention group compared with the usual care group at 6 and 12 months (P ≤ .01) but was not sustained at 24 months.

Table Graphic Jump LocationTable 2. WC During and After Interventiona

Table 3 and Table 4 present the secondary outcome measures. A significant main effect was observed for change in body weight, BMI, and body fat percentage in response to the intervention compared with usual care (P < .05 for all). The mean reduction for all 3 variables was greater in the intervention group compared with the usual care group at 6 and 12 months (P ≤ .005 for all) but was not sustained at 24 months (P ≥ .10 for all). For all 3 variables, significant within-group reductions were for the intervention alone (P < .01). For men, significant main effects for change in body weight (P = .01), BMI (P = .01), and body fat percentage (P = .04) were observed in the intervention group compared with the usual care group at 24 months. For women, no significant differences between treatment groups were observed for any anthropometric variable at 24 months (P > .05 for all).

Table Graphic Jump LocationTable 3. Anthropometric and Body Composition Variables During and After Interventiona
Table Graphic Jump LocationTable 4. Metabolic Risk Factors During and After Interventiona

No differences between groups were observed for any of the cardiometabolic risk factors or the metabolic syndrome at 24 months (P > .05); however, there were reductions within groups over time for several cardiometabolic variables (P < .05; Table 4). No differences between groups for men or women were observed for any of the cardiometabolic risk factors at 24 months (P > .05). However, the proportion of men with the metabolic syndrome at 24 months was reduced in response to the intervention compared with usual care (P = .03). At no point during follow-up was the prevalence of the metabolic syndrome different for women in the intervention compared with usual care.

Although no differences between groups were observed for physical activity levels at 24 months (data not shown), the reduction in WC was greater among men and women in the intervention group in the highest vs the lowest tertiles of change in physical activity (Figure 2; P = .04).

Place holder to copy figure label and caption
Graphic Jump Location

Figure 2. Changes in waist circumference (WC) during the 24-month study by tertile of change (low, medium, and high) in physical activity. * P < .05 compared with low tertile. † P < .01 compared with low tertile.

The participants' physicians did not change the prescription of medication for control of blood pressure and levels of glucose, low- and high-density lipoprotein cholesterol, and triglycerides in response to the intervention (Table 5). Cardiovascular events and resulting physician visits and hospitalizations were less common in the intervention group compared with the usual care group (Table 6). Rates of musculoskeletal injuries were similar between groups.

Table Graphic Jump LocationTable 5. Changes in Medication Use During Interventiona
Table Graphic Jump LocationTable 6. Adverse Events Reported by Participants as Occurring During 24 Months of Intervention and Usual Care

The primary finding of this trial is that a lifestyle-based intervention delivered by a trained health educator within the primary care setting was associated with significant reductions in abdominal obesity compared with usual care. However, the magnitude of the reduction in WC was modest and the effectiveness of the intervention was restricted to men, suggesting that behavioral interventions designed to reduce obesity may be sex dependent.

Our finding that WC in response to an intensive behavioral intervention was reduced at 24 months contrasts with previous studies in which attempts by primary care physicians alone to provide low- to moderate-intensity counseling failed to achieve or sustain weight loss.6,16 Our findings also contrast with those of Logue et al,17 who conducted a 2-year randomized clinical trial with 665 overweight and obese adults from 15 primary care sites. In that study, the combination of mailed patient materials and monthly telephone calls aimed at increasing physical activity and consumption of a balanced diet failed to achieve a reduction in WC. The reductions we observed in abdominal obesity are similar to those reported in response to a more intensive lifestyle modification program implemented in primary care that included on-site supervised aerobic and resistance exercise.18 Our principal finding also differs from the recent findings of the Practice-Based Opportunities for Weight Reduction Trial at the University of Pennsylvania (POWER-UP trial), in which obese patients in primary care randomized to a 2-year lifestyle intervention provided by the combination of the primary care provider (quarterly visits) and lifestyle coaches (monthly visits) did not reduce body weight compared with usual care by the primary care provider alone.19 However, in the POWER-UP trial, an enhanced counseling strategy that combined the behavioral intervention with meal replacement or pharmacological (orlistat or sibutramine hydrochloride) intervention achieved significant weight loss at 2 years compared with usual care.

Although the reduction in WC we observed was maintained at 2 years in men, the magnitude of the reduction was modest, and the major improvement occurred in the first 6 months with a general erosion of benefit during the remaining 18 months. This pattern of attenuated benefit over time is not uncommon to lifestyle-based interventions regardless of setting. Similar to our finding with WC, the weight reduction in response to the enhanced lifestyle intervention compared with usual care in the POWER-UP trial at 12 months was substantially reduced in the second year,19 suggesting that in both studies the benefit may have been abolished with longer follow-up. These findings confirm that much of the benefit in response to lifestyle intervention in primary care settings regardless of the counseling model used occurs early during the intensive phase, with a general erosion of benefit during the maintenance phase characterized by a tapering of contact with the patient. Whether increasing the frequency of contact face-to-face or electronically (eg, booster sessions) would facilitate adherence to healthy behaviors and associated obesity reduction in a cost-effective manner remains to be demonstrated.

The principal finding from our study and others also reinforces the challenges inherent to the sustained adoption of healthy behaviors in today's environment and suggests that the prevention of weight gain combined with modest reduction in WC during the 2-year study may reflect a more realistic expectation. Even a modest reduction in WC has benefits because, for a given BMI, increases in WC are positively associated with increased risk of mortality20 and cardiovascular disease.21

It is suggested that men show greater weight loss than women in response to diet and exercise.22 We confirmed that, for WC and the metabolic syndrome, men in the intervention group responded favorably compared with the usual care group, whereas women did not. Reasons for the observed sex difference are unclear. Our intervention was delivered by female health educators to all participants, and adherence throughout the intervention was similar, with men and women both attending 73.5% of the planned sessions. Although men sustained reductions in WC throughout the 2-year intervention, the women in the intervention group responded well in the first year but showed notable recidivism in the second year. The intervention provided fewer person-to-person contacts in the second year. The reduced contact frequency in the second year may be effective for men to maintain behaviors that result in favorable changes in WC and metabolic risk factors but may have negatively affected behavioral adherence in women. Alternatively, our finding is consistent with other reports that women are more resistant than men to a change in body weight or body composition consequent to lifestyle intervention alone.22,23 Whether resistance to weight loss and/or a failure to achieve one's WC or weight loss expectations affects women's adherence to treatment differently than men's is unclear.24

That our behavioral intervention was not associated with improvement in the cardiometabolic risk factors is consistent with other reports in which modest reductions in WC were observed consequent to prolonged16,18 or short-term follow-up.25 It is possible that the reduction in WC or body weight observed is below the threshold required for reduction in cardiometabolic risk. Alternatively, the lack of treatment effect may be explained by the observation that about 40% of our participants were taking medications to lower lipid levels or blood pressure, and baseline values were well within the clinically acceptable range. That our behavioral intervention was not associated with a reduction in the proportion of participants with the metabolic syndrome contrasts with shorter-term (12-month) trials that report a lowering of metabolic syndrome prevalence in response to diet and/or exercise compared with control arms in obese adults.26,27 In those studies, the reduction in the prevalence of the metabolic syndrome was removed after statistical control for weight loss26 or body fat loss.27 Our sex-based analyses support this observation because, in contrast to women, men within the intervention group reduced body weight, WC, and total adiposity. Concurrently, the proportion of men in the intervention group with the metabolic syndrome was reduced by approximately 20% at 2 years compared with men in the usual care group.

Strengths of the PROACTIVE trial include excellent adherence during the intervention and a favorable retention rate compared with obesity-related pharmacological trials that routinely report loss to follow-up of 40% to 50%.28,29 The intervention was delivered entirely within the primary care setting, facilitating direct communication between the physician and the health educator without disturbing the flow of patients or the regular practice of the physicians. That both men and women attended 73.5% of the planned counseling sessions confirms the willingness of patients to participate in long-term interventions located in primary care settings. The intervention was completed with no increase in musculoskeletal injuries and fewer cardiovascular complications. Our sample was diverse in age, sex, and medication use, making our findings generalizable; however, the participants were abdominally obese and predominantly white. Lack of objective measures for physical activity may have limited our ability to detect small differences between groups. Our study was not designed to test the relative contributions of dietary changes, increased physical activity, and weight loss to the reduction in WC or the metabolic syndrome; thus, the independent effects of these components remain to be determined. However, that changes in WC were positively associated with increases in physical activity in a dose-response manner (Figure 2) is consistent with established observations.30 Whether incorporating health educators into primary care settings is cost-effective remains to be determined.

Given the high prevalence of obesity and related medical complications, primary care providers will continue to encounter obese patients at exceedingly high rates. Our primary finding that intensive behavioral counseling delivered by trained experts in collaboration with the primary care physician can effectively achieve even modest reduction in abdominal obesity is encouraging. However, our findings also suggest that effective translation of obesity-reduction strategies in primary care settings may be sex dependent.

Correspondence: Robert Ross, PhD, School of Kinesiology and Health Studies, 28 Division St, Queen's University, Kingston, ON K7L 3N6, Canada (rossr@queensu.ca).

Accepted for Publication: December 9, 2011.

Published Online: February 27, 2012. doi:10.1001/archinternmed.2011.1972

Author Contributions: Dr Ross has full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Ross, Lam, Blair, Church, Godwin, Hotz, Johnson, Katzmarzyk, and Lévesque. Acquisition of data: Ross, Godwin, Johnson, and MacDonald. Analysis and interpretation of data: Ross, Lam, Church, Godwin, Johnson, and MacDonald. Drafting of the manuscript: Ross, Church, and Johnson. Critical revision of the manuscript for important intellectual content: Ross, Lam, Blair, Godwin, Hotz, Johnson, Katzmarzyk, Lévesque, and MacDonald. Statistical analysis: Lam, Church, and Johnson. Obtained funding: Ross, Lam, and Godwin. Administrative, technical, and material support: Ross, Godwin, and Hotz. Study supervision: Ross, Godwin, Hotz, Johnson, Lévesque, and MacDonald.

Financial Disclosure: Dr Ross receives honoraria for lectures from scientific, educational, and lay groups; has received research funding from the Canadian Institutes of Health Research, Heart and Stroke Foundation of Ontario, Marks Work Warehouse, Theratechnologies, and sanofi-aventis; and is a member of the advisory boards of the Canadian Sugar Institute and the International Chair for Cardiometabolic Risk. Dr Blair serves on the medical/scientific advisory boards of Alere, Technogym, Jenny Craig, Clarity Project, and Fit Steps for Life; has received unrestricted research grants from BodyMedia and Coca-Cola; receives book royalties from Human Kinetics; and receives honoraria for consultations and lectures from educational, scientific, public, and corporate groups. Dr Church receives honoraria for lectures from scientific, educational, and lay groups; has received research funding from the American Heart Association and the National Institutes of Health; oversaw study sites for pharmaceutical trials funded by sanofi-aventis, Orexigen, Arena, and Amylin; is a member of the Jenny Craig advisory board; and is a consultant to Technogym, Trestle Tree, Neuliven Health, and Coca-Cola.

Funding/Support: This study was supported by research grant OHN-63277 from the Canadian Institutes of Health.

Role of the Sponsors: The funding sponsor had no role in the design or protocol development or in the conducting of the trial, data collection, data analysis, or preparation of the manuscript.

National Heart, Lung, and Blood Institute.  Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: The Evidence Report. Bethesda, MD: National Heart, Lung, and Blood Institute; September 1998. Report 98-4083
Klein S, Burke LE, Bray GA,  et al; American Heart Association Council on Nutrition, Physical Activity, and Metabolism.  Clinical implications of obesity with specific focus on cardiovascular disease: a statement for professionals from the American Heart Association Council on Nutrition, Physical Activity, and Metabolism: endorsed by the American College of Cardiology Foundation.  Circulation. 2004;110(18):2952-2967
PubMed   |  Link to Article
Ma J, Xiao L, Stafford RS. Adult obesity and office-based quality of care in the United States.  Obesity (Silver Spring). 2009;17(5):1077-1085
PubMed   |  Link to Article
Foster GD, Wadden TA, Makris AP,  et al.  Primary care physicians' attitudes about obesity and its treatment.  Obes Res. 2003;11(10):1168-1177
PubMed   |  Link to Article
Jay M, Kalet A, Ark T,  et al.  Physicians' attitudes about obesity and their associations with competency and specialty: a cross-sectional study.  BMC Health Serv Res. 2009;9:106
PubMed  |  Link to Article   |  Link to Article
Tsai AG, Wadden TA. Treatment of obesity in primary care practice in the United States: a systematic review.  J Gen Intern Med. 2009;24(9):1073-1079
PubMed   |  Link to Article
LeBlanc E, O’Connor E, Whitlock EP, Patnode C, Kapka T. Screening for and Management of Obesity and Overweight in Adults. Rockville, MD: Agency for Healthcare Research and Quality; October 2011:40-41. Evidence Report No. 89. AHRQ publication No. 11-05159-EF-1. http://www.uspreventiveservicestaskforce.org/uspstf11/obeseadult/obesees.pdf. Accessed August 23, 2011
Ross R, Blair SN, Godwin M,  et al.  Prevention and Reduction of Obesity through Active Living (PROACTIVE): rationale, design and methods.  Br J Sports Med. 2009;43(1):57-63
PubMed   |  Link to Article
Prochaska JO, DiClemente CC, Norcross JC. In search of how people change: applications to addictive behaviors.  Am Psychol. 1992;47(9):1102-1114
PubMed   |  Link to Article
Prochaska JO, DiClemente CC. Toward a comprehensive model of change. In: Miller WE, Heather N, eds. Treating Addictive Behaviors. New York, NY: Plenum Press; 1986:3-27
Bandura A. Social Foundations of Thought and Action: A Social Cognitive TheoryEnglewood Cliffs, NJ: Prentice Hall; 1986
Blair SN, Haskell WL, Ho P,  et al.  Assessment of habitual physical activity by a seven-day recall in a community survey and controlled experiments.  Am J Epidemiol. 1985;122(5):794-804
PubMed
Ross R, Berentzen T, Bradshaw A,  et al.  Does the relationship between waist circumference, morbidity and mortality depend on measurement protocol for waist circumference?  Obes Res. 2008;9(4):312-325
PubMed   |  Link to Article
Alberti KG, Eckel RH, Grundy SM,  et al; International Diabetes Federation Task Force on Epidemiology and Prevention; National Heart, Lung, and Blood Institute; American Heart Association; World Heart Federation; International Atherosclerosis Society; International Association for the Study of Obesity.  Harmonizing the metabolic syndrome: a joint interim statement of the International Diabetes Federation Task Force on Epidemiology and Prevention; National Heart, Lung, and Blood Institute; American Heart Association; World Heart Federation; International Atherosclerosis Society; and International Association for the Study of Obesity.  Circulation. 2009;120(16):1640-1645
PubMed   |  Link to Article
Little R, Yau L. Intent-to-treat analysis for longitudinal studies with drop-outs.  Biometrics. 1996;52(4):1324-1333
PubMed   |  Link to Article
ter Bogt NC, Bemelmans WJ, Beltman FW, Broer J, Smit AJ, van der Meer K. Preventing weight gain by lifestyle intervention in a general practice setting: three-year results of a randomized controlled trial.  Arch Intern Med. 2011;171(4):306-313
PubMed   |  Link to Article
Logue E, Sutton K, Jarjoura D, Smucker W, Baughman K, Capers C. Transtheoretical model–chronic disease care for obesity in primary care: a randomized trial.  Obes Res. 2005;13(5):917-927
PubMed   |  Link to Article
Eriksson MK, Franks PW, Eliasson M. A 3-year randomized trial of lifestyle intervention for cardiovascular risk reduction in the primary care setting: the Swedish Björknäs study.  PLoS One. 2009;4(4):e5195
PubMed  |  Link to Article   |  Link to Article
Wadden TA, Volger S, Sarwer DB,  et al.  A two-year randomized trial of obesity treatment in primary care practice.  N Engl J Med. 2011;365(21):1969-1979
PubMed   |  Link to Article
Berentzen TL, Jakobsen MU, Halkjaer J, Tjønneland A, Overvad K, Sørensen TI. Changes in waist circumference and mortality in middle-aged men and women.  PLoS One. 2010;5(9):e13097
PubMed  |  Link to Article   |  Link to Article
Emerging Risk Factors Collaboration. Wormser D, Kaptoge S, DiAngelantonio E,  et al.  Separate and combined associations of body-mass index and abdominal adiposity with cardiovascular disease: collaborative analysis of 58 prospective studies.  Lancet. 2011;377(9771):1085-1095
PubMed  |  Link to Article
Donnelly JE, Hill JO, Jacobsen DJ,  et al.  Effects of a 16-month randomized controlled exercise trial on body weight and composition in young, overweight men and women: the Midwest Exercise Trial.  Arch Intern Med. 2003;163(11):1343-1350
PubMed   |  Link to Article
Graffagnino CL, Falko JM, La Londe M,  et al.  Effect of a community-based weight management program on weight loss and cardiovascular disease risk factors.  Obesity (Silver Spring). 2006;14(2):280-288
PubMed   |  Link to Article
Dalle Grave R, Calugi S, Molinari E,  et al; QUOVADIS Study Group.  Weight loss expectations in obese patients and treatment attrition: an observational multicenter study.  Obes Res. 2005;13(11):1961-1969
PubMed   |  Link to Article
Church TS, Blair SN, Cocreham S,  et al.  Effects of aerobic and resistance training on hemoglobin A1c levels in patients with type 2 diabetes: a randomized controlled trial.  JAMA. 2010;304(20):2253-2262
PubMed   |  Link to Article
Camhi SM, Stefanick ML, Katzmarzyk PT, Young DR. Metabolic syndrome and changes in body fat from a low-fat diet and/or exercise randomized controlled trial.  Obesity (Silver Spring). 2010;18(3):548-554
PubMed   |  Link to Article
Phelan S, Wadden TA, Berkowitz RI,  et al.  Impact of weight loss on the metabolic syndrome.  Int J Obes (Lond). 2007;31(9):1442-1448
PubMed   |  Link to Article
Després JP, Golay A, Sjöström L.Rimonabant in Obesity-Lipids Study Group.  Effects of rimonabant on metabolic risk factors in overweight patients with dyslipidemia.  N Engl J Med. 2005;353(20):2121-2134
PubMed   |  Link to Article
James WP, Caterson ID, Coutinho W,  et al; SCOUT Investigators.  Effect of sibutramine on cardiovascular outcomes in overweight and obese subjects.  N Engl J Med. 2010;363(10):905-917
PubMed   |  Link to Article
Slentz CA, Duscha BD, Johnson JL,  et al.  Effects of the amount of exercise on body weight, body composition, and measures of central obesity: STRRIDE—a randomized controlled study.  Arch Intern Med. 2004;164(1):31-39
PubMed   |  Link to Article

Figures

Place holder to copy figure label and caption
Graphic Jump Location

Figure 2. Changes in waist circumference (WC) during the 24-month study by tertile of change (low, medium, and high) in physical activity. * P < .05 compared with low tertile. † P < .01 compared with low tertile.

Place holder to copy figure label and caption
Graphic Jump Location

Figure 1. Participant flow diagram.

Tables

Table Graphic Jump LocationTable 6. Adverse Events Reported by Participants as Occurring During 24 Months of Intervention and Usual Care
Table Graphic Jump LocationTable 5. Changes in Medication Use During Interventiona
Table Graphic Jump LocationTable 4. Metabolic Risk Factors During and After Interventiona
Table Graphic Jump LocationTable 3. Anthropometric and Body Composition Variables During and After Interventiona
Table Graphic Jump LocationTable 2. WC During and After Interventiona
Table Graphic Jump LocationTable 1. Participant Characteristicsa

References

National Heart, Lung, and Blood Institute.  Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: The Evidence Report. Bethesda, MD: National Heart, Lung, and Blood Institute; September 1998. Report 98-4083
Klein S, Burke LE, Bray GA,  et al; American Heart Association Council on Nutrition, Physical Activity, and Metabolism.  Clinical implications of obesity with specific focus on cardiovascular disease: a statement for professionals from the American Heart Association Council on Nutrition, Physical Activity, and Metabolism: endorsed by the American College of Cardiology Foundation.  Circulation. 2004;110(18):2952-2967
PubMed   |  Link to Article
Ma J, Xiao L, Stafford RS. Adult obesity and office-based quality of care in the United States.  Obesity (Silver Spring). 2009;17(5):1077-1085
PubMed   |  Link to Article
Foster GD, Wadden TA, Makris AP,  et al.  Primary care physicians' attitudes about obesity and its treatment.  Obes Res. 2003;11(10):1168-1177
PubMed   |  Link to Article
Jay M, Kalet A, Ark T,  et al.  Physicians' attitudes about obesity and their associations with competency and specialty: a cross-sectional study.  BMC Health Serv Res. 2009;9:106
PubMed  |  Link to Article   |  Link to Article
Tsai AG, Wadden TA. Treatment of obesity in primary care practice in the United States: a systematic review.  J Gen Intern Med. 2009;24(9):1073-1079
PubMed   |  Link to Article
LeBlanc E, O’Connor E, Whitlock EP, Patnode C, Kapka T. Screening for and Management of Obesity and Overweight in Adults. Rockville, MD: Agency for Healthcare Research and Quality; October 2011:40-41. Evidence Report No. 89. AHRQ publication No. 11-05159-EF-1. http://www.uspreventiveservicestaskforce.org/uspstf11/obeseadult/obesees.pdf. Accessed August 23, 2011
Ross R, Blair SN, Godwin M,  et al.  Prevention and Reduction of Obesity through Active Living (PROACTIVE): rationale, design and methods.  Br J Sports Med. 2009;43(1):57-63
PubMed   |  Link to Article
Prochaska JO, DiClemente CC, Norcross JC. In search of how people change: applications to addictive behaviors.  Am Psychol. 1992;47(9):1102-1114
PubMed   |  Link to Article
Prochaska JO, DiClemente CC. Toward a comprehensive model of change. In: Miller WE, Heather N, eds. Treating Addictive Behaviors. New York, NY: Plenum Press; 1986:3-27
Bandura A. Social Foundations of Thought and Action: A Social Cognitive TheoryEnglewood Cliffs, NJ: Prentice Hall; 1986
Blair SN, Haskell WL, Ho P,  et al.  Assessment of habitual physical activity by a seven-day recall in a community survey and controlled experiments.  Am J Epidemiol. 1985;122(5):794-804
PubMed
Ross R, Berentzen T, Bradshaw A,  et al.  Does the relationship between waist circumference, morbidity and mortality depend on measurement protocol for waist circumference?  Obes Res. 2008;9(4):312-325
PubMed   |  Link to Article
Alberti KG, Eckel RH, Grundy SM,  et al; International Diabetes Federation Task Force on Epidemiology and Prevention; National Heart, Lung, and Blood Institute; American Heart Association; World Heart Federation; International Atherosclerosis Society; International Association for the Study of Obesity.  Harmonizing the metabolic syndrome: a joint interim statement of the International Diabetes Federation Task Force on Epidemiology and Prevention; National Heart, Lung, and Blood Institute; American Heart Association; World Heart Federation; International Atherosclerosis Society; and International Association for the Study of Obesity.  Circulation. 2009;120(16):1640-1645
PubMed   |  Link to Article
Little R, Yau L. Intent-to-treat analysis for longitudinal studies with drop-outs.  Biometrics. 1996;52(4):1324-1333
PubMed   |  Link to Article
ter Bogt NC, Bemelmans WJ, Beltman FW, Broer J, Smit AJ, van der Meer K. Preventing weight gain by lifestyle intervention in a general practice setting: three-year results of a randomized controlled trial.  Arch Intern Med. 2011;171(4):306-313
PubMed   |  Link to Article
Logue E, Sutton K, Jarjoura D, Smucker W, Baughman K, Capers C. Transtheoretical model–chronic disease care for obesity in primary care: a randomized trial.  Obes Res. 2005;13(5):917-927
PubMed   |  Link to Article
Eriksson MK, Franks PW, Eliasson M. A 3-year randomized trial of lifestyle intervention for cardiovascular risk reduction in the primary care setting: the Swedish Björknäs study.  PLoS One. 2009;4(4):e5195
PubMed  |  Link to Article   |  Link to Article
Wadden TA, Volger S, Sarwer DB,  et al.  A two-year randomized trial of obesity treatment in primary care practice.  N Engl J Med. 2011;365(21):1969-1979
PubMed   |  Link to Article
Berentzen TL, Jakobsen MU, Halkjaer J, Tjønneland A, Overvad K, Sørensen TI. Changes in waist circumference and mortality in middle-aged men and women.  PLoS One. 2010;5(9):e13097
PubMed  |  Link to Article   |  Link to Article
Emerging Risk Factors Collaboration. Wormser D, Kaptoge S, DiAngelantonio E,  et al.  Separate and combined associations of body-mass index and abdominal adiposity with cardiovascular disease: collaborative analysis of 58 prospective studies.  Lancet. 2011;377(9771):1085-1095
PubMed  |  Link to Article
Donnelly JE, Hill JO, Jacobsen DJ,  et al.  Effects of a 16-month randomized controlled exercise trial on body weight and composition in young, overweight men and women: the Midwest Exercise Trial.  Arch Intern Med. 2003;163(11):1343-1350
PubMed   |  Link to Article
Graffagnino CL, Falko JM, La Londe M,  et al.  Effect of a community-based weight management program on weight loss and cardiovascular disease risk factors.  Obesity (Silver Spring). 2006;14(2):280-288
PubMed   |  Link to Article
Dalle Grave R, Calugi S, Molinari E,  et al; QUOVADIS Study Group.  Weight loss expectations in obese patients and treatment attrition: an observational multicenter study.  Obes Res. 2005;13(11):1961-1969
PubMed   |  Link to Article
Church TS, Blair SN, Cocreham S,  et al.  Effects of aerobic and resistance training on hemoglobin A1c levels in patients with type 2 diabetes: a randomized controlled trial.  JAMA. 2010;304(20):2253-2262
PubMed   |  Link to Article
Camhi SM, Stefanick ML, Katzmarzyk PT, Young DR. Metabolic syndrome and changes in body fat from a low-fat diet and/or exercise randomized controlled trial.  Obesity (Silver Spring). 2010;18(3):548-554
PubMed   |  Link to Article
Phelan S, Wadden TA, Berkowitz RI,  et al.  Impact of weight loss on the metabolic syndrome.  Int J Obes (Lond). 2007;31(9):1442-1448
PubMed   |  Link to Article
Després JP, Golay A, Sjöström L.Rimonabant in Obesity-Lipids Study Group.  Effects of rimonabant on metabolic risk factors in overweight patients with dyslipidemia.  N Engl J Med. 2005;353(20):2121-2134
PubMed   |  Link to Article
James WP, Caterson ID, Coutinho W,  et al; SCOUT Investigators.  Effect of sibutramine on cardiovascular outcomes in overweight and obese subjects.  N Engl J Med. 2010;363(10):905-917
PubMed   |  Link to Article
Slentz CA, Duscha BD, Johnson JL,  et al.  Effects of the amount of exercise on body weight, body composition, and measures of central obesity: STRRIDE—a randomized controlled study.  Arch Intern Med. 2004;164(1):31-39
PubMed   |  Link to Article

Correspondence

CME
Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
Submit a Comment

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Web of Science® Times Cited: 8

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Collections
PubMed Articles
JAMAevidence.com

The Rational Clinical Examination EDUCATION GUIDES
Abdominal Aortic Aneurysm