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Intensive behavioural therapy

Regular behavioural counselling leads to significant weight loss

The significant weight loss experienced by participants who received liraglutide, in addition to IBT, is consistent with previous studies of existing weight loss medications

Intensive behavioural therapy (IBT), which provides diet and physical activity counselling, is proven to help adults with obesity achieve meaningful weight loss in six to 12 months, according to researchers from the Perelman School of Medicine at the University of Pennsylvania. The study is the first randomised controlled evaluation of the efficacy of IBT when implemented under the Centers for Medicare and Medicaid Services (CMS) coverage guidelines.

The trial, led by Dr Tom Wadden, a professor of Psychology in Psychiatry and Dr Jena Tronieri, an assistant professor of Psychology in Psychiatry, both in the Perelman School of Medicine at the University of Pennsylvania, showed that patients who received IBT lost an average of 6.1 percent of their initial body weight at one year. The study, ‘Behavioral Therapy for Obesity Combined with Liraglutide 3.0 mg: A Randomized Controlled Trial’, was published in Obesity.

Tom Wadden

Medicare beneficiaries with obesity, defined by a BMI>30, are eligible to receive IBT from a qualified health professional in a primary care setting. CMS covers weekly counselling visits for the first month, and then sessions every other week for the next five months. Patients who lose 3kgs (6.6 pounds) or more are eligible for six additional monthly sessions. Most private health insurers offer more limited coverage, if any at all, of IBT for obesity.

"Intensive behavioural counselling is a proven method for helping people modify their eating and physical activity habits and achieve significant weight loss," said Wadden. "We hope the findings from our study will encourage broader use of behavioural weight loss counselling under the CMS benefit and in other primary care settings."

In the study, 150 participants with obesity were randomly assigned to one of three treatment groups with each providing distinct, one-year intervention regimens. Participants in each group received 21, individual IBT counselling sessions, as provided under the CMS coverage guidelines.

  • In group one, participants were counselled by a physician, nurse practitioner or registered dietitian, and were instructed to consume a diet of 1200 to 1800 calories a day (based on their body weight) and to gradually increase their physical activity to 225 minutes per week.
  • In addition to the IBT, participants in the second group received liraglutide 3.0mg, a medication approved by the FDA for chronic weight management.
  • Participants in the third group received the IBT counselling, liraglutide and a prescription for 12 weeks of daily meal replacements.

Outcomes

The study showed that 44 percent of the participants in the first group (those who received IBT alone) lost 5 percent or more of baseline body weight, a measure of clinically meaningful weight loss. More than 70 percent of the participants in both the second and third groups lost 5 percent or more of their baseline body weight. Mean losses for IBT‐alone, IBT‐liraglutide and multi-component participants were 6.1 ± 1.3%, 11.5 ± 1.3% and 11.8 ± 1.3% of baseline weight, respectively (Figure 1). Fully 44.0%, 70.0%, and 74.0% of these participants lost ≥ 5% of weight, respectively. The liraglutide‐treated groups were superior to IBT‐alone on both outcomes.

Figure 1: Estimated mean percentage reduction in baseline weight over 52 weeks in the intention‐to‐treat‐population (n=150, with 50 participants in each treatment group)

The significant weight loss experienced by participants who received liraglutide, in addition to IBT, is consistent with previous studies of existing weight loss medications. All three interventions also were associated with improvements in average systolic and diastolic blood pressure, waist circumference, triglycerides, symptoms of depression and clinically meaningful improvements in cardiometabolic risk factors.

Liraglutide appears to induce weight loss, in part, by decreasing hunger and increasing the feeling of fullness after eating, according to additional data presented by Tronieri at Obesity Week, an international conference held in Nashville, Tennessee. Tronieri studied a subset of patients in the larger trial and found that participants who received IBT-liraglutide, compared with IBT-alone, reported significantly greater reductions in hunger and preoccupation with food during the first 24 weeks. Tronieri's study found no significant differences between the two groups in reported appetite control at weeks 40 or 52, though IBT-liraglutide participants still maintained nearly double the weight loss.

The IBT study also revealed that participants treated by a physician or nurse practitioner lost comparable amounts of weight to the participants treated by a registered dietitian, underscoring the feasibility of educating primary care practitioners to provide this kind of therapy.

Jena Tronieri

"We encourage CMS to expand the scope of practitioners who are eligible to provide IBT independently, which is currently limited to physicians, nurse practitioners, physician assistants and nurse specialists," said Tronieri. "Registered dietitians, health counsellors and nursing assistants can be trained to effectively deliver IBT, which would help expand access to this critical intervention and, ultimately, help the many Americans who struggle with obesity and its associated health complications."

Wadden and Tronieri, along with their colleagues at Penn's Center for Weight and Eating Disorders, where the study was conducted, believe their findings need to be replicated in a larger sample of participants who are treated in primary care practices, rather than in a specialised weight management clinic like Penn's.

"As we move forward, we need to assess the effectiveness and cost of providing IBT in person, versus delivering it via a digital platform, like a mobile app or online patient portal," said Wadden said. "Millions of Americans could benefit from IBT, and we need to find low-cost, effective ways of getting it to them."

To access this paper, please click here

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