Success of Online Educational Interventions on Obesity ...img.medscapestatic.com › pi › edu ›...

Authors: Amy Larkin, PharmD; Stacey Hughes; Kristin Richardson; Anne Le, PharmD

Medscape Education, New York, NY

introduction

Educational and Research Goals:

Obesity is a major public health crisis that touches healthcare professionals in every specialty. In the past 10 years, the prevalence of obesity (body mass index [BMI] ≥30 kg/m2) in the United States has increased from 20.0% to 35.7% of the population.1.2 Current trends project 65 million more obese adults in the United States by 2030, contributing to an excess of 8 million cases of diabetes, 6.8 million cases of coronary heart disease and stroke, and more than 500,000 cases of cancer.3 Although lifestyle modifications such as diet and exercise intervention are cornerstones of care, pharmacotherapy should be considered for individuals with a BMI 30 kg/m2 or greater or for those with a BMI 27 kg/m2 or greater when comorbidities are present.4,5 Despite the consequences of obesity and recent classification as a disease, many patients who are obese/overweight continue to go untreated.

• Educate healthcare providers involved in the care of patients who are obese/overweight about safe and effective treatment plans for weight loss

• Improve clinician knowledge and competence of weight loss plans so they can safely and effectively use them in practice and provide better care for their patients

• Determine if online continuing medical education (CME) interventions directed to primary care physicians (PCPs) and endocrinologists in the United States can improve knowledge about and appropriate treatment of patients who are obese and overweight

methods

Success of Online Educational Interventions on Obesity Management

Educational Interventions:• PCPs and endocrinologists participated in at least 1 of 3

online CME activities within a curriculum Activity 1: Goals of Weight-Loss Therapy and Strategies for Attainment • Series of 6 video commentaries with slides

Activity 2: Obesity Management Today: Elevating Care via New Therapeutic Options • Video panel discussion with slides

Activity 3: Does One Size Fit All in Obesity Management? • Video panel discussion with slides

• All activities were housed as a collection on Medscape Education

• Content was developed with input from a steering committee consisting of expert faculty in the field of obesity

• The effects of the education were assessed by CE Outcomes using clinical case vignettes

• Results were compared with responses from demographically similar control groups (nonparticipants) in order to determine the impact of the education

• The domains measured included weight loss, lifestyle modifications, pharmacotherapy, and patient communication

Statistical Analysis:• For the case-vignette questions, χ2 tests were conducted to

detect significant differences between the responses of the participant and nonparticipant groups

• When the analysis involved the comparison of responses where 1 answer is evidence-based and thus preferred, the P value represents the level of significant difference between the participant and nonparticipant groups in the selection of that response

• When the analysis involved the comparison of responses where no response is preferred (eg, in questions that assess confidence), the P value represents the level of significant difference in the distribution of response selection between the participant and nonparticipant groups

• The level of statistical significance for analytical tests was set at P ≤.05

• The educational effect size was calculated using Cohen’s d formula to determine the average amount of difference between participants and nonparticipants

• Effect sizes greater than 0.8 are large, between 0.8 and 0.4 are medium, and less than 0.4 are small

results

RefeRences 1. US Centers for Disease Control and Prevention (CDC). Behavioral risk factor surveillance system. Prevalence and trends data. 2012. http://apps.nccd.cdc.gov/

brfss/ Accessed March 30, 2012.

2. Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of obesity in the United States, 2009–2010. NCHS data brief, no 82. Hyattsville, MD: National Center for Health Statistics. 2012.

3. Wang YC, McPherson K, Marsh T, Gortmaker SL, Brown M. Health and economic burden of the projected obesity trends in the USA and the UK. Lancet. 2011;378:815-825.

4. Kang JG, Park CY. Anti-obesity drugs: a review about their effects and safety. Diabetes Metab J. 2012;36:13-25.

5. National Heart Lung and Blood Institute (NHLBI). Practical Guide to the Identification, Evaluation and Treatment of Overweight and Obesity in Adults. Bethesda, MD: Public Health Service, US Department of Health and Human Services; 2000.

PCPs Endocrinologists

Participant(n = 70)

Nonparticipant(n = 70)

Participant(n = 30)


Patients treated per week for obesity, mean

18 18 18 20

Number of patients treated per week for obesity

1-56-1011-1516-2021-2526-3031-35

10%21%10%19%14%10%16%

10%21%10%19%14%10%16%

10%27%23%7%3%

10%20%

10%10%20%10%10%13%27%


Participant(n = 70)


Participant(n = 30)



17 17 18 20


1-56-1011-1516-2021-2526-3031-35

10%21%16%19%13%7%

14%

10%20%16%20%13%7%

14%

17%17%17%13%7%7%

23%

7%10%27%10%17%10%20%


Participant(n = 70)


Participant(n = 30)



24 24 22 23


1-56-1011-1516-2021-2526-3031-35

0%6%7%

19%21%16%31%

0%6%7%

19%21%16%31%

3%7%

20%20%7%

13%30%

3%3%

20%13%13%13%33%

Activity 1: Goals of Weight-Loss Therapy and Strategies for Attainment

Activity 2: Obesity Management Today: Elevating Care via New Therapeutic Options

Activity 3: Does One Size Fit All in Obesity Management?

A total of 210 PCPs and 90 endocrinologists across all 3 activities were included in the assessment.

Scan here to view this poster online.

Case: A 61-year-old divorced truck driver comes to see you, motivated to lose weight and improve his overall health. He has a medical history significant for type 2 diabetes, coronary artery disease, hypertension, nephrolithiasis, hyperlipidemia, gastroesophageal reflux disease, and osteoarthritis. He had single-vessel coronary artery bypass grafting 12 years ago and right hip replacement 3 years ago. His current medications include metformin, sitagliptin, enalapril, carvedilol, atorvastatin, omeprazole, and aspirin. He has a 40-pack-per-year smoking history but quit 2 years ago when he met his current girlfriend. He drinks 4 to 6 beers per week and is almost completely sedentary. His height is 6’1”, weight is 274 lbs, and BMI is 36.1 kg/m2. His waist circumference is 42”, and blood pressure is 135/80 mm Hg. Recent labs reveal the following: glycated hemoglobin = 8.4%; fasting lipid profile: total cholesterol = 160 mg/dL, low-density lipoprotein cholesterol = 106 mg/dL, high-density lipoprotein cholesterol = 30 mg/dL, and triglycerides = 120 mg/dL. He has previously enrolled together with his girlfriend in Weight Watchers on 2 separate occasions and lost a modest amount of weight, only to regain it within a couple of months.

Case: A single 44-year-old woman comes to your office seeking help in losing weight. Her employer has recently instituted a new wellness program, which provides incentives for overweight and obese employees who make organized weight management attempts. She has tried a number of commercial programs and diets in the past. She has also used a number of freely available weight loss supplements. Her weight has fluctuated for several years. She has heard that new weight loss medications have recently become available and would strongly like to try a prescription medication for weight loss.She has generally been healthy apart from a history of gallstones and a cholecystectomy 5 years ago. She does not smoke and rarely consumes alcohol. She does no form of exercise and is mostly sedentary at work. Physical examination reveals height of 5’7” and weight of 237 lbs (BMI=37 kg/m2). Her vital signs are otherwise normal as is the remainder of her physical examination. You tell her that you are willing to consider a newer anti-obesity drug in conjunction with lifestyle changes and careful monitoring for adverse effects.

Domain 3: Pharmacotherapy

100%

80%

60%

40%

20%

0%

100%

80%

60%

40%

20%

0%

100%

80%

60%

40%

20%

0%

100%

80%

60%

40%

20%

0%

PCP P =.004Endo P =.004

PCP Nonparticipants (n = 70)Endocrinologist Nonparticipants (n = 30)

PCP Participants (n = 70)Endocrinologist Participants (n = 30)

PCP P =.006Endo P >.99









Headache* Increases in blood pressure Constipation Difficulty concentrating

Hypercholesterolemia Increases in Increased blood pressurepressure

Dysgeusia* Increase in blood glucose

Refer him for bariatric surgery immediately due to

his BMI and significant comorbidities

Refer him back to a commercial weight loss program such as Weight

Watchers, since he has had success there before

Discuss pharmacotherapy for weight loss in addition to

lifestyle management*

Recommend lifestyle management only at this point, including caloric

restriction and moderate-intensity

physical activity

Obtaining a family history of obesity

Exploring his reasons for changing his behavior*

Exploring his motivation to overeat

Exploring his motivation to be sedentary

46%

70% 70%

33% 36%

11%

33%23%

10% 11%3% 3%

9% 7%

30%

3%

1% 3% 3%

69%

31%

67%

37%26%

61%

30%

57%

4% 4% 3% 3%0%

16%23%

13% 13%23%

9% 10%0%

31%

53% 57%

73%

30%

16%20%

13%

6% 3% 3% 3%

73%

87%84% 83%

13%9% 10% 7% 9% 4% 3% 3%

If you were to prescribe lorcaserin for this patient, which adverse effect would you warn her about? (select only 1)

Best answer shown with *.

100%

80%

60%

40%

20%

0%

100%

80%

60%

40%

20%

0%

100%

80%

60%

40%

20%

0%

PCP P <.001Endo P =.04



















physical activity





1% 3% 3%

69%

31%

67%

37%26%

61%

30%

57%

4% 4% 3% 3%0%

16%23%

13% 13%23%

9% 10%0%

31%

53% 57%

73%

30%

16%20%

13%

6% 3% 3% 3%

73%

87%84% 83%

13%9% 10% 7% 9% 4% 3% 3%

If you were to prescribe phentermine/topiramate SR for this patient, which adverse effect would you warn her about? (select only 1)


100%

80%

60%

40%

20%

0%

100%

80%

60%

40%

20%

0%

PCP P =.01Endo P =.18














physical activity





16%23%

13% 13%23%

9% 10%0%

31%

53% 57%

73%

30%

16%20%

13%

6% 3% 3% 3%

73%

87%84% 83%

13%9% 10% 7% 9% 4% 3% 3%

Which ONE of the following steps are you most likely to take at this point? (select only 1)


Domain 1: Weight Loss

Domain 2: Lifestyle Modifications

100%

80%

60%

40%

20%

0%

100%

80%

60%

40%

20%

0%

100%

80%

60%

40%

20%

0%

100%

80%

60%

40%

20%

0%

100%

80%

60%

40%

20%

0%

100%

80%

60%

40%

20%

0%



















Low-protein diets have been shown consistently to be superior to other diets in

promoting weight loss

Low-fat diets have been shown consistently to be superior to other diets in


Low-carbohydrate diets have been shown consistently to be superior to other diets in


The macronutrient composition of diets is not a significant predictor of

weight loss*












physical activity





< 5% 5-10%* 11-15% 16-20%

4%0%0%

44%

23%27% 23%

39%

61%70% 70%

3% 3%3%11%

17%

46%

70% 70%

33% 36%

11%

33%23%

10% 11%3% 3%

9% 7%

30%

3%

4%

66%

86%90% 93%

23%

7% 7% 7% 7%4% 3% 3%0% 0% 0%

1% 3% 3%

69%

31%

67%

37%26%

61%

30%

57%

4% 4% 3% 3%0%

16%23%

13% 13%23%

9% 10%0%

31%

53% 57%

73%

30%

16%20%

13%

6% 3% 3% 3%

73%

87%84% 83%

13%9% 10% 7% 9% 4% 3% 3%

What percentage of her body weight would you tell her that she needs to lose to reduce her risk of comorbid conditions? (select only 1)


100%

80%

60%

40%

20%

0%

100%

80%

60%

40%

20%

0%

100%

80%

60%

40%

20%

0%

100%

80%

60%

40%

20%

0%

100%

80%

60%

40%

20%

0%
















Low-protein diets have been shown consistently to be superior to other diets in


Low-fat diets have been shown consistently to be superior to other diets in


Low-carbohydrate diets have been shown consistently to be superior to other diets in


The macronutrient composition of diets is not a significant predictor of

weight loss*












physical activity





4%0%0%

44%

23%27% 23%

39%

61%70% 70%

3% 3%3%11%

17%

46%

70% 70%

33% 36%

11%

33%23%

10% 11%3% 3%

9% 7%

30%

3%

1% 3% 3%

69%

31%

67%

37%26%

61%

30%

57%

4% 4% 3% 3%0%

16%23%

13% 13%23%

9% 10%0%

31%

53% 57%

73%

30%

16%20%

13%

6% 3% 3% 3%

73%

87%84% 83%

13%9% 10% 7% 9% 4% 3% 3%


Domain 4: Patient Communication

Case: A divorced 36-year-old Mexican American receptionist and mother of 3 whom you are seeing comes to you for a routine annual checkup. She has a past medical history of hypertension, diagnosed 4 years ago; gestational diabetes mellitus; and mild, idiopathic hirsutism. Her current medications include lisinopril 20 mg 1 tablet daily and a daily multivitamin. She drinks only on rare occasions and has never smoked cigarettes. Physical examination reveals a BMI of 31.25 kg/m2 and blood pressure of 136/82 mm Hg. Her remaining vital signs are normal. The remainder of her physical examination is normal except for excess hair growth along both cheeks and along the midline of her abdomen. She has acanthosis nigricans on her posterior neck and in both axillae. You tell the patient you are concerned about her weight. She informs you that she has struggled with her weight since the birth of her first child 15 years ago. She has tried the Atkins diet but was not able to stick with it for a prolonged period. She tells you she is very motivated to lose weight. She is completely sedentary and has not participated in any exercise since she was in high school. You open a discussion about diet and exercise with the patient. The patient asks you what type of diet she should select for weight loss.

Case: A 58-year-old married tax accountant comes to see you at the urging of his wife because he has not seen a physician for several years, and he has a family history of heart disease. He has a history of chronic low back pain. He has no other medical conditions. His only medication is ibuprofen for back pain, which he uses from time to time. He has no allergies. He neither drinks nor smokes. Physical examination reveals a BMI of 30.1 kg/m2. His vital signs and the remainder of his physical examination are normal.

100%

80%

60%

40%

20%

0%

PCP P =.10Endo P =.72







6% 3% 3% 3%

73%

87%84% 83%

13%9% 10% 7% 9% 4% 3% 3%

Engaging this patient in motivational interviewing includes which one of the following? (select only 1)

From case above

What would you tell her regarding various diet types? (select only 1)answer)


notes:

For more information, contact Amy Larkin, PharmD, Director of Clinical Strategy, Medscape, LLC, at [email protected].

Source of Support:This curriculum of CME activities was supported by an independent educational grant from Eisai Inc.

Conclusions

This study demonstrated the effectiveness of a curriculum-style educational intervention on improving the knowledge, competence, and performance of PCPs and endocrinologists in management of patients who are obese and overweight. Based on the results of the analysis, future education is needed regarding the role of lifestyle changes as an integral component to managing patients with obesity, differences in the various weight-reducing agents and their mechanisms of actions as a way to individualize treatment plans, side effect profiles of weight loss medications, and designing appropriate obesity management treatment plans that are safe and comprehensive.

Case Continued: She tells you that she would like to lose at least 75 lbs with medication and lifestyle changes. She has heard of phentermine/topiramate sustained release (SR) and would like to consider starting this medication in combination with lifestyle changes.

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