ORIGINAL INVESTIGATION Weight Control in the Physician’s Office Judith M. Ashley, PhD, RD; Sachiko T. St Jeor, PhD; Jon P. Schrage, MD, MPA; Suzanne E. Perumean-Chaney, MS; Mary C. Gilbertson, PhD, RD; Nanette L. McCall, RD; Vicki Bovee, MS, RD Background: Lifestyle changes involving diet, behav- ments was as effective as the traditional dietitian-led group ior, and physical activity are the cornerstone of success- intervention not using meal replacements (mean±SD ful weight control. Incorporating meal replacements (1-2 weight loss, 4.3%±6.5% vs 4.1%±6.4%, respectively). per day) into traditional lifestyle interventions may of- Comparison of the dietitian-led groups showed that fer an additional strategy for overweight patients in the women using meal replacements maintained a signifi- primary care setting. cantly greater weight loss (9.1%±8.9% vs 4.1%±6.4%) (P=.03). Analysis across groups showed that weight loss Methods: One hundred thirteen overweight premeno- of 5% to 10% was associated with significant (P = .01) pausal women (mean±SD age, 40.4±5.5 years; weight, reduction in percentage of body fat, body mass index, waist 82±10 kg; and body mass index, 30±3 kg/m2) partici- circumference, resting energy expenditure, insulin level, pated in a 1-year weight-reduction study consisting of total cholesterol level, and low-density lipoprotein cho- 26 sessions. The women were randomly assigned to 3 dif- lesterol level. Weight loss of 10% or greater was associ- ferent traditional lifestyle-based groups: (1) dietitian- ated with additional significant (P = .05) improvements led group intervention (1 hour per session), (2) dietitian- in blood pressure and triglyceride level. led group intervention incorporating meal replacements (1 hour per session), or (3) primary care office interven- Conclusions: A traditional lifestyle intervention using tion incorporating meal replacements with individual phy- meal replacements can be effective for weight control and sician and nurse visits (10-15 minutes per visit). reduction in risk of chronic disease in the physician’s of- fice setting as well as in the dietitian-led group setting. Results: For the 74 subjects (65%) completing 1 year, the primary care office intervention using meal replace- Arch Intern Med. 2001;161:1599-1604 ECENT SURVEYS have shown ject to “an ideal weight,” a difficult task that Americans are getting for those faced with this condition. How- heavier, with an estimated ever, new guidelines based on more re- 97 million adults classified cent evidence suggest that small weight as overweight or obese.1 losses (5%-10% of initial body weight) can Obesity fulfills the criteria of a chronic dis- improve obesity-related health complica- R 1,3-8 ease and is associated with considerable tions. In addition, the maintenance of increases in morbidity and mortality. It is modest reductions, even with partial lifelong or lasts many years, is progres- weight regain, is frequently sufficient to sive and relapsing, and is associated with sustain improvements in health,9,10 par- a wide range of comorbid conditions, in- ticularly if healthy diets and increases in cluding coronary heart disease, type 2 dia- physical activity are maintained. betes, hypertension, and dyslipidemia.1 The Physician recommendations have direct cost of obesity is estimated to be al- consistently been shown to exert a pow- From the Nutrition Education most 6% of our national health expendi- erful influence on patient behavior.11,12 Un- and Research Program ture, but the relative costs and benefits of fortunately, the health care community as (Drs Ashley, St Jeor, various approaches to control obesity are a whole is not as active as it might be in Gilbertson, and Bovee not available.2 the treatment of obesity as a chronic dis- and Mss Perumean-Chaney 13,14 and McCall) and Department The vast majority of the excess bur- ease. In a recent national survey, nearly of Internal Medicine den of overweight and obesity is in those 40% of women and 25% of men who were (Dr Schrage), University subjects with a moderately high body mass overweight or obese reported having ever of Nevada School of index (BMI).3 The traditional goal of received medical counseling about the ad- Medicine, Reno. therapy has been the reduction of a sub- verse health consequences of increased (REPRINTED) ARCH INTERN MED/ VOL 161, JULY 9, 2001 WWW.ARCHINTERNMED.COM 1599 ©2001 American Medical Association. All rights reserved. Downloaded From: http://archinte.jamanetwork.com/ by Kris Marinos on 06/11/2015 SUBJECTS AND METHODS to subjects. Diet instruction included a low-calorie diet of approximately 1200 kcal/d (with no more than 30% of calories from fat) using the US Department of Agriculture SUBJECTS food guide pyramid food groups and portion sizes to ensure adequate nutrients and a variety of foods. Activity Overweight or obese premenopausal women aged 25 to 50 instruction as a method of self-motivation included increas- years with a BMI (calculated as weight in kilograms di- ing energy expenditure by walking up to 10000 steps a vided by the square of height in meters) between 25 and day as measured by a pedometer (Yamax Digi-Walker; 35 were selected from a larger sample responding to me- Yamax Inc, Tokyo, Japan) that was supplied to each par- dia announcements and flyers distributed in the local com- ticipant. Subjects completed homework assignments that munity. After being screened by a telephone question- recommended recording food intake and activity levels. naire, interested women attended a group orientation There were 3 traditional lifestyle-based intervention meeting, at which the objectives and protocols of the study groups: were explained before written consent was obtained. Ex- clusion criteria included current chronic or psychological Group 1: Traditional Dietitian-Led Intervention Group disease, abnormal serum laboratory values of clinical sig- nificance, or current hormone-replacement therapies. In Subjects in group 1 (n=37) attended small classes (8-10 addition, women were excluded who were pregnant, plan- subjects per class) led by a registered dietitian. A total of ning to become pregnant, lactating, or planning to move 26 one-hour sessions were held weekly for the first 3 out of the area within the following year. Eligible women months (introduction and 12 sessions), biweekly for the were scheduled for a 1-hour clinic assessment to deter- second 3 months (6 sessions), and monthly for the final 6 mine their fasting serum chemistry, lipid, insulin, and glu- months (6 sessions and a 1-year session). The diet con- cose values; weight; height; BMI; waist circumference; body sisted of all meals and snacks prepared from self-selected fat percentage, resting energy expenditure (kilocalories per conventional foods following 1200 kcal/d using the US 24 hours); blood pressure; dieting history; eating and ac- Department of Agriculture food guide pyramid. tivity habits; and psychosocial status. Only those subjects who obtained a medical release form signed by their phy- Group 2: Traditional Dietitian-Led Intervention Group sician were admitted to the study. There were no costs to Incorporating Meal Replacements subjects for assessment measures, lifestyle-modification ma- terials, consultations (whether provided in the physi- Similar to group 1, subjects in this intervention group cian’s office or in groups), or meal-replacement products. (n=38) also attended small classes led by a registered di- The University of Nevada Human Subjects Committee ap- etitian, including the 26 sessions held on the same proved all procedures used in this study. weekly, biweekly, and monthly schedule. This group fol- lowed similar self-selected diets; however, 2 of the 3 main LIFESTYLE INTERVENTION meals (breakfast, lunch, or dinner) were replaced with meal-replacement shakes or meal-replacement bars Subjects were randomly assigned to 1 of 3 interventions, as (Slim·Fast; Slim·Fast Foods Co, West Palm Beach, Fla). described below. All subjects attended a total of 26 ses- Each liquid meal-replacement shake contained 220 kcal, sions during the 1-year study and received instruction 7 to 10 g of protein, 40 to 46 g of carbohydrates (of which manuals that included lessons based on the Lifestyle, Exer- 5 g was dietary fiber), and 1.5 to3goffat, and was supple- cise, Attitude, Relationships, and Nutrition (LEARN) Pro- mented with 15% to 100% of the percentage of daily value gram for Weight Control.21 At each session, 1 of 26 inter- for essential vitamins and minerals. Each meal-replace- vention lessons of the treatment manuals was distributed ment bar contained 220 kcal,8gofprotein, 33 to 36 g of weight.15 To encourage health providers to increase their using meal replacements within the time constraints ex- involvement in obesity management, effective and prac- isting in the general office practice of medicine? Second, tical lifestyle intervention options that can be delivered can a traditional lifestyle-modification program adminis- in a busy clinical setting are needed.14,16 Recent reports tered by a registered dietitian using a meal-replacement strat- indicate that meal replacements coupled with a low- egy be as effective as the same program using a standard calorie diet can offer an effective option for long-term com- food plan exchange strategy? A further aim of this study pliance or improvements in metabolic risk factors in clinic was to evaluate the potential health benefits of sustained patients.17-20 These studies examined a meal-replace- weight loss for specific chronic disease risk factors associ- ment intervention in a university-based clinic, in a com- ated with the moderately overweight and obese. munity-based intervention program, or with minimal clinic intervention. The present study is the first ran- RESULTS domized trial to compare the use of meal replacements in an established university-based weight loss clinic and WEIGHT AND RISK FACTOR COMPARISONS a primary care physician practice.