By Monique Tello, MD, MPH
July 25, 2019
It’s remarkable to me that while overweight and obesity are major epidemic medical problems resulting in many clinical complications, and we have solid scientific evidence showing us safe, effective interventions that actually help people to lose weight, we are not yet incorporating these methods into primary care. What’s our problem?
Want to know more about what works for weight loss? I’ll tell you: behavioral change support, in the form of a health coach.
What the Diabetes Prevention Program taught us about lifestyle intervention
We have good data on this approach going back decades, via the very successful Diabetes Prevention Program. This program took almost 3,000 people who were at risk for type 2 diabetes and gave them either a 24-week diet and lifestyle intervention, a medication (metformin), or a placebo (a fake pill) to see if anything could lower their risk for developing diabetes. The very comprehensive diet and lifestyle intervention had the goal of changing participants’ daily habits, and in addition to some classes teaching basic nutrition and behavioral strategies for weight loss and physical activity, it also offered lifestyle coaches with frequent contact with participants, supervised physical activity sessions, and good clinical support for reinforcing an individualized plan.
Perhaps not surprisingly, the diet and lifestyle approach was incredibly effective: after three years, this group lost more weight (15 pounds average) and had a 58 percent lower risk of developing diabetes than the placebo group. The diet and lifestyle effect lasted: even after ten years, this group maintained almost 5 lbs of weight loss and had a 34 percent lower risk of developing diabetes compared to the placebo group.
But, it’s been very difficult to get similar programs up and running. Why not try to incorporate these supported behavior-change principals into a program that is delivered as part of regular primary care, like say, at your doctor’s office?
Incorporating behavior-change principals in clinical practice
A practice at Massachusetts General Hospital has done just that. They have incorporated a certified health coach who, upon referral from the PCP, reaches out to patients and facilitates a patient-centered action plan. The coach uses a variety of proven techniques including appreciative inquiry, motivational interviewing, self-determination theory, transtheoretical model, positive psychology, and relational flow to help identify patients’ goals and counsel them around potential obstacles.
Not all patients receive coaching, so they did a study to see what happened with those who do. The results are incredibly promising and were published in the American Journal of Lifestyle Medicine. They looked at 271 patients with overweight or obesity, divided into four groups:
1. A coached group, who received weight loss coaching for at least 3 months
2. A comparison group, who declined or did not receive coaching
3. A dropout group, who initially accepted coaching but did not complete it
4. A non-weight-coached group, who received coaching for other reasons than weight loss.
The results were impressive! After one year, the coached group lost 7.2% of body weight, which was fifteen pounds on average. This effect stuck even at 24 months, with a maintained weight loss of 6.8% of body weight. And most visits with the coach were by phone.
These findings are incredibly important, because we know from the Diabetes Prevention Program that a weight loss of just 5% total body weight can lower the risk of developing diabetes, and is associated with many other positive health outcomes.
Why aren’t we offering this sort of supported behavior change in every primary care doctor’s office across the country? The first argument is that it’s too expensive. After all, as these study authors point out, health coaching is not reimbursed by insurance companies—at all. So they did a cost analysis, and figured out that assuming a $60,000 annual salary of the health coach, the cost per coached patient is about $289 per year (for all patients). For those who used the services more (and achieved minimum weight loss of 5% total body weight) the cost was $480 per patient per year.
Call to action
This is actually peanuts compared to the costs of weight loss surgery (and without the inherent risks) or even most commercial weight loss programs (which produce unreliable results). The study’s main author, Ben Crocker, MD, states that this work is a major call to action to encourage health insurers to reimburse medical practices for health coaching.
- 10-year follow-up of diabetes incidence and weight loss in the Diabetes Prevention Program Outcomes Study. The Lancet, November 14, 2009.
- Primary Care-Based Health Coaching Intervention for Weight Loss in Overweight/ Obese Adults: A 2-Year Experience. American Journal of Lifestyle Medicine, March-April 2019
Learn more about the HMS CME Online course:
Lifestyle Medicine: Nutrition and the Metabolic Syndrome
Monique Tello is a practicing physician at Massachusetts General Hospital, clinical instructor at Harvard Medical School, and author of Healthy Habits for Your Heart. Monique is also a contributing editor for Harvard Health Publishing and she writes a popular blog, http://www.generallymedicine.com, about achieving balance, health, and wellness from the perspective of doctor and mother.
Follow Dr. Tello on Twitter: @drmoniquetello
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