Stepped-care intervention results in weight loss, at lower cost

June 26, 2012

Although a standard behavioral weight loss intervention among overweight and obese adults resulted in greater average weight loss over 18 months, a stepped care intervention resulted in clinically meaningful weight loss that cost less to implement, according to a study in the June 27 issue of JAMA.

"Most programs are intensive during the initial weeks of treatment, become less intensive over time, and maintain a fixed contact schedule for participants irrespective of or failure. Intensive weight loss programs are costly and require substantial time commitments from the participants, making them impractical in many circumstances. An alternative is a stepped-care approach. It involves an initially low-intensity intervention that is increased if weight loss milestones are not achieved at fixed time points. Stepped care has been effective for treatment of other . In theory, stepped care could result in better weight loss than because treatment intensity is escalated if weight loss goals are not met during the treatment period," according to background information in the article. "If shown to be an effective and a lower cost alternative to traditional in-person programs, a stepped-care approach could prove to be a cost-effective means for ."

John M. Jakicic, Ph.D., of the University of Pittsburgh, and colleagues examined whether a stepped-care weight loss intervention (STEP) would result in greater weight loss compared with a standard behavioral weight loss intervention (SBWI). The clinical trial included 363 overweight and obese adults (: 25-<40; age: 18-55 years, 33 percent nonwhite, and 83 percent female) who were randomized to SBWI (n = 165) or STEP (n=198). Participants were enrolled between May 2008 and February 2010 and data collection was completed by September 2011. All participants were placed on a low-calorie diet, prescribed increases in physical activity, and attended group counseling sessions ranging from weekly to monthly during an 18-month period. The SBWI group was assigned to a fixed program. Counseling frequency, type, and weight loss strategies could be modified every 3 months for the STEP group in response to observed weight loss as it related to weight loss goals.

Of the 363 , 260 (71.6 percent) provided a measure of weight at the 18-month assessment. The researchers found that weight loss at 18 months was -7.6 kg (16.8 lbs.) in the SBWI group compared with -6.2 kg (13.7 lbs.) in the STEP group. The percentage change in weight from baseline to 18 months was -8.1 percent in the SBWI group compared with -6.9 percent in the STEP group.

Both groups had significant and comparable improvements in resting heart rate, blood pressure level, and fitness.

"From the payer perspective, the mean cost per participant was $358 for the STEP group and $494 for the SBWI group. Costs from the participant perspective also were lower in the STEP group ($427) per participant compared with the SBWI group ($863). From the societal perspective (i.e., the sum of payer and participant), the average cost for STEP was $785. This was significantly less expensive than the average cost for SBWI, which was estimated to be $1,357," the authors write.

The researchers add that using the base-case cost estimates, they found that from the societal perspective, relative to status quo, the incremental cost-effectiveness ratio for STEP was $127 per 1 kg (2.2 lbs.) of weight lost. "The incremental cost-effectiveness ratio for SBWI, relative to the less expensive STEP, was $409 per 1 kg of weight lost. From the payer perspective, the incremental cost-effectiveness ratios were reduced to $58 per 1 kg of weight lost for STEP and $97 per 1 kg of weight lost for SBWI."

"Among overweight and , the use of SBWI resulted in a greater mean weight loss than STEP over 18 months. STEP resulted in clinically meaningful weight loss that cost less to implement than SBWI. Whether this weight loss results in improved health-related outcomes warrants further investigation," the authors conclude.

"Obesity is one of the most important and most frustrating health problems that physicians treat, and the studies in this issue of JAMA provide valuable information for clinicians who treat obese patients," writes George A. Bray, M.D., of the Pennington Biomedical Research Center, Baton Rouge, La., in an accompanying editorial.

"It may be possible to have a more individualized approach to weight loss, rather than a one-size-fits-all approach. The most efficient treatment approach incorporates periodic reassessments and adjustment of the weight loss regimen based on a patient's success at any given time."

"This trial thus shows that the novel approach of spending more time and effort on patients who need it most may be more economical than implementing a standard protocol for all participants re­gardless of their response. Despite the successes of the ap­proaches used in the study by Jakicic et al, the findings do not answer the question of how to achieve weight loss in a manner that will be appealing enough to the participants to result in long-term, sustained weight loss."

More information: JAMA. 2012;307[24]:2617-2626.
JAMA. 2012;307[24]:2641-2642.

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