Can strategies intended to improve how care is organised or delivered to people with overweight or obesity lead to greater weight reduction?

What is the aim of this review?

To assess the effectiveness of strategies to change the behaviour of health professionals and the organisation of care to promote weight reduction in people with overweight and obesity. This is an update of a Cochrane Review.

Key messages

We found little evidence for a clinically important intervention effect on weight loss, or on body mass index (BMI) change. The results suggest that a brief educational intervention provided to healthcare professionals may lead to a slight decrease in weight for their adult patients, but the results of the studies were not consistent. Evidence for all the other interventions we looked at came mostly from single studies, which is why these interventions need further investigation.

What was studied in the review?

The number of people with overweight or obesity is increasing around the world. Excessive weight is associated with many chronic diseases.

We searched the literature for studies that evaluated the effects of interventions aimed at changing the behaviour of health professionals or the way care is organised for improved weight management and weight loss.

What are the main results of this review?

We included 12 studies, eight in adults and four in children. One hundred and thirty-nine family practices were included, providing care to 89,754 people who were followed for 12 months. Seven studies evaluated the effects of various interventions directed at healthcare professionals (i.e. education, reminders, and decision support tools), and the other five evaluated different organisational interventions (i.e. changes in who delivers the health care, how and where it is delivered, etc.). The comparison intervention was standard care, or the opportunity to seek it. The main outcomes assessed were weight or weight change for adults, and how their weight compared with their peers for children.

Professional interventions

Brief education of primary care physicians in weight management may slightly decrease the weight of their patients, .

Tailoring the education to the healthcare professional to improve how closely they follow guidelines probably led to little or no difference in obesity management or weight loss at study end.

We are uncertain whether issuing doctors with printed reminders about weight management strategies helped to reduce their patients' weight, compared to standard care.

Two studies reported that providing doctors with a clinical decision support tool within the practice may lead to little or no difference in the BMI of children with obesity or in the weight of adults with overweight or obesity, compared to patients receiving standard care.

Organisational interventions

Two studies assessed the effect of multidisciplinary teams. Weight-loss programmes led by a dietitian or by a doctor plus a dietitian may lead to greater weight loss in adult patients than standard care. Shared care (between family practice and hospital doctors and dietitians) probably leads to little or no difference in the BMI of children with obesity, compared to standard care.

Organisational restructuring of the delivery of family practice care (i.e. introducing the chronic care model: training of the whole practice team, enhanced electronic medical record system, the paediatric nurse practitioners playing a key role in delivering the intervention) led to a slightly lower increase in the BMI of children with obesity at intervention clinics, compared to standard care.

Two studies assessed changes in the setting of service delivery. The use of both mail and phone interventions to promote weight loss probably led to little or no difference in weight loss of adults with overweight or obesity, compared to standard care. Family practice weight management programmes conducted by nurses may lead to little or no difference in BMI in children with obesity, as compared to specialist obesity hospital clinics run by consultants.

How up-to-date is this review?

The review authors searched for studies up to September 2016.

Authors' conclusions: 

We found little convincing evidence for a clinically-important effect on participants' weight or BMI of any of the evaluated interventions. While pooled results from three studies indicate that educational interventions targeting healthcare professionals may lead to a slight weight reduction in adults, the certainty of these results is low. Two trials evaluating CDS tools (unpooled results) for improved weight management suggest little or no effect on weight or BMI change in adults or children with overweight or obesity. Evidence for all the other interventions evaluated came mostly from single studies. The certainty of the included evidence varied from moderate to very low for the main outcomes (weight and BMI). All of the evaluated interventions would need further investigation to ascertain their strengths and limitations as effective strategies to change the behaviour of healthcare professionals or the organisation of care. As only two studies reported on cost, we know little about cost effectiveness across the evaluated interventions.

Read the full abstract...
Background: 

The prevalence of overweight and obesity is increasing globally, an increase which has major implications for both population health and costs to health services. This is an update of a Cochrane Review.

Objectives: 

To assess the effects of strategies to change the behaviour of health professionals or the organisation of care compared to standard care, to promote weight reduction in children and adults with overweight or obesity.

Search strategy: 

We searched the following databases for primary studies up to September 2016: CENTRAL, MEDLINE, Embase, CINAHL, DARE and PsycINFO. We searched the reference lists of included studies and two trial registries.

Selection criteria: 

We considered randomised trials that compared routine provision of care with interventions aimed either at changing the behaviour of healthcare professionals or the organisation of care to promote weight reduction in children and adults with overweight or obesity.

Data collection and analysis: 

We used standard methodological procedures expected by Cochrane when conducting this review. We report the results for the professional interventions and the organisational interventions in seven 'Summary of findings' tables.

Main results: 

We identified 12 studies for inclusion in this review, seven of which evaluated interventions targeting healthcare professional and five targeting the organisation of care. Eight studies recruited adults with overweight or obesity and four recruited children with obesity. Eight studies had an overall high risk of bias, and four had a low risk of bias. In total, 139 practices provided care to 89,754 people, with a median follow-up of 12 months.

Professional interventions

Educational interventions aimed at general practitioners (GPs), may slightly reduce the weight of participants (mean difference (MD) -1.24 kg, 95% confidence interval (CI) -2.84 to 0.37; 3 studies, N = 1017 adults; low-certainty evidence).

Tailoring interventions to improve GPs' compliance with obesity guidelines probably leads to little or no difference in weight loss (MD 0.05 (kg), 95% CI -0.32 to 0.41; 1 study, N = 49,807 adults; moderate-certainty evidence).

It is uncertain if providing doctors with reminders results in a greater weight reduction than standard care (men: MD -11.20 kg, 95% CI -20.66 kg to -1.74 kg, and women: MD -1.30 kg, 95% CI [-7.34, 4.74] kg; 1 study, N = 90 adults; very low-certainty evidence).

Providing clinicians with a clinical decision support (CDS) tool to assist with obesity management at the point of care leads to little or no difference in the body mass index (BMI) z-score of children (MD -0.08, 95% CI -0.15 to -0.01 in 378 children; moderate-certainty evidence), CDS tools may lead to little or no difference in weight loss in adults: MD -0.095 kg (-0.21 lbs), P = 0.47; 1 study, N = 35,665; low-certainty evidence.

Organisational interventions

Adults with overweight or obesity may lose more weight if the care was provided by a dietitian (by -5.60 kg, 95% CI -4.83 kg to -6.37 kg) or by a doctor-dietitian team (by -6.70 kg, 95% CI -7.52 kg to -5.88 kg; 1 study, N = 270 adults; low-certainty evidence). Shared care leads to little or no difference in the BMI z-score of children with obesity (adjusted MD -0.05, 95% CI -0.14 to 0.03; 1 study, N = 105 children; low-certainty evidence).

Organisational restructuring of the delivery of primary care (i.e. introducing the chronic care model) may result in a slightly lower increase in the BMI of children who received care at intervention clinics (BMI change: adjusted MD -0.21, 95% CI -0.50 to 0.07; 1 study, unadjusted MD -0.18, 95% CI -0.20 to -0.16; N=473 participants; moderate-certainty evidence).

Mail and phone interventions probably lead to little or no difference in weight loss in adults (mean weight change (kg) using mail: -0.36, 95% CI -1.18 to 0.46; phone: -0.44, 95% CI -1.26 to 0.38; 1 study, N = 1801 adults; moderate-certainty evidence). Care delivered by a nurse at a primary care clinic may lead to little or no difference in the BMI z-score in children (MD -0.02, 95% CI -0.16 to 0.12; 1 study, N = 52 children; very low-certainty evidence).

Two studies reported data on cost effectiveness: one study favoured mail and standard care over telephone consultations, and the other study achieved weight loss at a modest cost in both intervention groups (doctor and doctor-dietitian). One study of shared care reported similar adverse effects in both groups.

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