Tool kit provides real world guidelines for counseling for weight loss in primary care

Healthcare practitioners and researchers have a new tool to combat obesity in primary care settings, according to a study published in Obesity, the flagship journal of The Obesity Society.

In 2011, the Centers for Medicare and Medicaid Services (CMS) began covering intensive behavioral therapy (IBT) for obesity when provided to qualified beneficiaries in primary care settings. The benefit provides weekly, brief (15 minute) visits the first month, followed by every-other week visits in months 2-6. Patients who lose 3 kg (6.6 lb) at month 6 are eligible for monthly brief (15 minute) visits in months 7-12 to facilitate weight loss maintenance. This sums to a maximum of 22 possible visits in 1 year.

"CMS's IBT benefit for obesity represents a major advance in recognizing the perils of obesity and the health benefits of moderate weight loss. We hope that CMS's historic decision in covering IBT for obesity will encourage other insurers and employers to do so," writes author Thomas Wadden, Professor of Psychology in Psychiatry at the Perelman School of Medicine, a colleague of co-author Jena Tronieri at the University of Pennsylvania's Center for Weight and Eating Disorders in Philadelphia. Adam Tsai, an obesity medicine physician at Kaiser Permanente Colorado in Denver, and at the University of Colorado, School of Medicine, in Aurora also co-authored the paper.

Wadden and colleagues, however, note that CMS has not provided an evidence-based treatment manual for physicians and other qualified practitioners to use in delivering IBT to patients. CMS now recommends that practitioners follow a 5As approach (i.e., assess, advise, agree, assist, and arrange) in providing weight management, but the efficacy of this approach is not well established.

To fill this gap, Wadden notes that "we are pleased to provide practitioners access to our 21-session treatment manual, which is modeled on the schedule of visits recommended by CMS. Our manual is adapted from the widely used Diabetes Prevention Program. In the first randomized assessment of this brief IBT approach, modeled on the CMS schedule, participants lost a mean of 5.4 percent of initial weight at 6 months, which increased to 6.1 percent at 1 year."

"These are favorable weight losses," noted Tsai. "We hope that our IBT manual will help practitioners in primary care settings achieve comparable results."

In an accompanying commentary, Scott Kahan, MD, FTOS, and Steven Heymsfield, MD, FTOS, applaud the MODEL-IBT program, writing that "Wadden and colleagues offer a gift to struggling HCPs," who traditionally receive little or no education on obesity during medical training. "For those HCPs who crave practical, real-world assistance to better support their patients...the MODEL-IBT curriculum will be a welcome resource."

In their article, the authors also encourage CMS to expand the range of practitioners who can provide IBT to include registered dietitians (RD), health counselors, psychologists, and other allied health professionals. Currently some of these practitioners can deliver services "incident to" CMS-approved providers, who include physicians, nurse practitioners, nurse specialists, and physician assistants.

However, a CMS-approved provider must be physically present at the time a RD or other auxiliary professional delivers care, thus, limiting the opportunity to do so. The authors also call for the coverage of remotely-delivered IBT, where shown to be effective. "We need to find more efficient, less expensive methods of delivering IBT to the millions of Americans who can benefit from it," said Tronieri.

The study, titled " A Protocol to Deliver Intensive Behavioral Therapy (IBT) for Obesity in Primary Settings: The MODEL-IBT Program" will be published online ahead of the October 2019 print issue. The acronym MODEL refers to Managing Obesity with Diet, Exercise, and Liraglutide. The weight loss medication (liraglutide) was added to IBT with one group of patients in the randomized trial described earlier and which was published in Obesity in January 2019.