Treatment of Obesity in Primary Care Practice in the United States:
A Systematic Review
Adam Gilden Tsai, MD, MSCE
and Thomas A. Wadden, PhD
Division of General Internal Medicine, Department of Medicine, University of Colorado Denver, Denver, CO, USA;
Center for Weight and
Eating Disorders, Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, USA.
OBJECTIVES: This review examines the results of
randomized controlled trials in which behavioral weight
loss interventions, used alone or with pharmacothera-
py, were provided in primary care settings.
DATA SOURCES: Literature search of MEDLINE,
PubMed, Cochrane Systematic Reviews, CINAHL, and
EMBASE (1950-present). Inclusion criteria for studies
were: (1) randomized trial, (2) obesity intervention in US
adults, and (3) conducted in primary care or explicitly
intended to model a primary care setting.
REVIEW METHODS: Both authors reviewed each study
to extract treatment modality, provider, setting, weight
change, and attrition. The CONSORT criteria were used
to assess study quality. Due to the small number and
heterogeneity of studies, results were summarized but
not pooled quantitatively.
RESULTS: Ten trials met the inclusion criteria. Studies
were classified as: (1) PCP counseling alone, (2) PCP
counseling + pharmacotherapy, and (3) “collaborative”
obesity care (treatment delivered by a non-physician
provider). Weight losses in the active treatment arms of
these categories of studies ranged from 0.1 to 2.3 kg,
1.7 to 7.5 kg, and 0.4 to 7.7 kg, respectively. Most
studies provided low- or moderate-intensity counseling,
as defined by the US Preventive Services Task Force.
CONCLUSIONS: Current evidence does not support the
use of low- to moderate-intensity physician counseling
for obesity, by itself, to achieve clinically meaningful
weight loss. PCP counseling plus pharmacotherapy, or
intensive counseling (from a dietitian or nurse) plus
meal replacements may help patients achieve this goal.
Further research is needed on different models of
managing obesity in primary care practice.
KEY WORDS: obesity; primary care; health-care providers; counseling;
J Gen Intern Med 24(9):1073–9
© Society of General Internal Medicine 2009
besity is a root cause of numerous conditions treated by
primary care providers (PCPs).
Weight loss can im-
prove health and reduce the risk of complications.
Preventive Services Task Force (“Task Force”)hasrecom-
mended that “clinicians screen all adult patients for obesity
and offer intensive counseling and behavioral interventions to
promote sustained weight loss for obese adults.”
counseling is defined as at least two visits per month for the
first 3 months.) This clearly is a tall order, given that 32% of
Americans are obese.
The American Medical Association
and the American
College of Physicians
also have published weight manage-
ment guidelines for clinicians. However, numerous barriers
exist to the provision of behavioral counseling by PCPs. They
include practitioners’ lack of time, skills, resources, and
reimbursement, as well as competing demands of the many
other recommended preventive services.
of the evidence for obesity treatment is derived from efficacy
studies that were conducted in academic medical centers and
that may have limited relevance for primary care.
Force acknowledged the potential difficulty of PCPs offering
intensive weight loss counseling and suggested that practi-
tioners consider referring patients for such care. The Task
Force also concluded that the evidence was “insufficient to
recommend for or against the use of moderate- or low-intensity
counseling” (i.e., less than two visits per month).
Practitioners and researchers know little about the efficacy
of behavioral weight loss interventions that can be delivered in
primary care practice.
The primary goal of this review is to
examine the results of studies that delivered behavioral
counseling alone or in combination with pharmacotherapy.
We examined studies of primary care-based weight loss
interventions in US adults. Inclusion criteria included: (1) the
study was a randomized controlled trial of a weight loss
intervention in adults; (2) counseling was conducted by a
PCP or another provider working in the primary care office (or
the trial was implemented in a setting explicitly intended to
simulate primary care); (3) the study was conducted in the US.
Exclusion criteria included: (1) intervention trials that were not
primary care-based; (2) non-US studies; (3) pediatric trials; (4)
studies based in primary care and related to obesity but that
were not intervention trials (e.g., surveys). We included only
studies from the US because we wished to assess the
effectiveness of interventions delivered in the context of this
nation’s health-care system.
Given the limited literature,
Received October 14, 2008
Revised February 9, 2009
Accepted June 3, 2009
Published online June 27, 2009