Neil Goldfarb Associate Dean for Research Joseph Yaskin, M.S.S. Project Manager

1. The Evidence Base for Effectiveness of Obesity Management Programs:A Comprehensive Review of the Literature Neil Goldfarb Associate Dean for Research Joseph Yaskin, M.S.S. Project Manager Richard Toner, M.S. Research Assistant Jefferson School of Population Health Philadelphia, PA

2. Presentation Goals • Brief Overview of Results • Clinical Interventions in Context • Population health • Role in chronic care management • Promising Directions for Future Research • Continuing Research at Jefferson

3. Obesity and Overweight, U.S.,20-74 year olds,1980-2006 (% of pop.) No Significant Change from 20042 Source: 1. CDC. 2. Ogden C et al. Prevalence of Overweight and Obesity in the United States, 1999-2004. JAMA. April 5, 2006 – Vol. 295.No.13. 2. Updated with NHANES 2005-06 Data.

4. Obesity Trends Among U.S. AdultsCDC (BRFSS, 1990, 1998, 2007) (*BMI 30, or about 30 lbs. overweight for 5’4” person) 1998 1990 2007 No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

5. History & Context • Supported by DMAA: The Care Continuum Alliance • Component of Obesity with Co-Morbidities Project • Goals: • Expand understanding of co-morbid obesity • Develop and disseminate best practices • Methods: • Peer-reviewed literature 2001-2007 • Methods accepted as best practices employed

6. What We Reviewed • Intervention categories • Behavioral • Pharmaceutical • Surgical Note: Population Health Management interventions partially examined

7. Preview of Findings • Effective: Weight-loss interventions combining two or more mechanisms of action often effective. • Not-effective: Pharmacologic and behavior-based interventions combined with a second mechanism of action.

8. Exercise Self-help Counseling Diet Combination of above Behavioral Interventions

9. Results - Behavior Interventions • Behavioral interventions may be appropriate for patients who need to lose modest amounts of weight. (Stevens, 2001) • Program intensity and maintenance of intervention over time associated with effectiveness

10. Pharmacologic Interventions • No evidence that one pharmacologic treatment is superior in effectiveness to another • No drugs produce placebo-subtracted weight losses of 10% or more (NIH) • Best results achieved when intensive lifestyle intervention is coupled with therapy.

11. Results: Pharmacologic Studies • Our review confirmed previous findings: • No studies of anti-obesity medications are associated with >10%, placebo subtracted, weight loss. 1 • Medication interventions must be part of a comprehensive chronic care management strategy. 2 • Combined with diet and behavioral lifestyle modification, pharmacologic treatment can yield 5-10% weight-loss. 1 Sources:1: Padwal R.S. Drug Treatments for obesity: orlistat, sibutramine, and rimonabant. Lancet 2007; 2: Bray GA. Medical Therapy for Obesity. Medical Clinics of North America (2007)

12. Restrictive Restricts stomach capacity, reducing food intake Adjustable Gastric Banding, Vertical Banded Gastroplasty Combined Restrictive / Malabsorptive Restricts stomach and amount of nutrients, calories absorbted Gastric Bypass, Bileopancreatic Diversion Surgical Interventions: Two Types R: The Cleveland Clinic (www.clevelandclinic.org)

13. Results: Surgical Interventions • Supporting evidence is well-established. • Approach is not appropriate for all patients. • Effectiveness hindered by post-operative complications, costly readmissions. • Costs: significant initial investment, attractive ROI (~6 years) with reduction in co-morbidities.

14. Summary of Review Results • Not Effective! • Any type of intervention administered without integration of a second type • Effective! • Medical OR Surgical interventions WITH: • strong behavior/lifestyle component, AND • personal commitment of patient • Selected stand-alone behavior interventions • Only long-term interventions (2 yrs +) with frequent clinical interaction, maximizing “dose effect.”

15. Obesity and Population Health • Consensus: • Obesity is an environmental health problem • Domains for population-health approach include • Communities and governments • Schools • Health payors, including • Employers • Insurers • Insurers and employers are emerging as driving forces in population health response.

16. Health Plans: Promising Practices • Provider incentives • Nutritional counseling • Physical activity goals • Patient-customized intervention • Community education and planning • Collaborations with employers • Value-based purchasing

17. Employers: Diverse Approaches • Wellness Plans • Many include support for weight loss • Diverse supports: • individualized coaching • large employers • discount memberships in commercial weight-loss programs • feasible for mid-size employers • Rewarding Healthy Lifestyles • recognition at department level • benefits & discounts

18. Case Study: Chronic Care Management • Kaiser-Permanente Health System • Serves 8.1 million people in 9 states (2005) • 11,000 physician providers • Employee population 100,000 + • National leader, electronic medical records

19. Case Study: Kaiser Permenente • Components in chronic care approach: • Evidence-based clinical practices and weight management interventions • Community health initiatives and grants • Educational theatre programs - health messages to kids • Farmers’ markets to create healthy food environments in and around Kaiser Permanente facilities • Sponsorship of a TV Turnoff campaign to reduce risks associated with excessive screen time Histon TM, Goeldner JL, Bachman KH, Rothert K. Kaiser Permanente's disease management approach to addressing the obesity epidemic. Journal of Clinical Outcomes Management 2005;12(9):464-469.

20. Promising Research Directions • Studies of synthesized approaches: clinical intervention, chronic care management and population health • New generation of cost-effectiveness studies to develop evidence-base for payer support • Long-term studies that yield genuine evidence relevant to successful management of obesity over the life course

21. Continuing Research: Phase 2 • Continuing collaboration with DMAA: The Care Continuum Alliance • Independent academic research, employing best practices • Dissemination will include creation of information products to integrate with actionable tools for employers, insurers, policymakers

22. Continuing Research: Phase 2 • Focus on population health perspective • Case-series study, qualitative exploration of workplace initiatives • Population-health literature review • Prototype algorithm derived from evidence-based guidelines, for integration with DMAA benefit design for obesity management

23. Contact information: Neil Goldfarb, Associate Dean for Research Jefferson School of Population Health neil.goldfarb@jefferson.edu (215) 955-0247