Marion Vetter

BACKGROUND: Calls for primary care providers (PCPs) to offer obese patients behavioral weight-loss counseling have not been accompanied by adequate guidance on how such care could be delivered. This randomized trial compared weight loss during a 2-year period in response to three lifestyle interventions, all delivered by PCPs in collaboration with auxiliary health professionals (lifestyle coaches) in their practices. METHODS: We randomly assigned 390 obese adults in six primary care practices to one of three types of intervention: usual care, consisting of quarterly PCP visits that included education about weight management; brief lifestyle counseling, consisting of quarterly PCP visits combined with brief monthly sessions with lifestyle coaches who instructed participants about behavioral weight control; or enhanced brief lifestyle counseling, which provided the same care as described for the previous intervention but included meal replacements or weight-loss medication (orlistat or sibutramine), chosen by the participants in consultation with the PCPs, to potentially increase weight loss. RESULTS: Of the 390 participants, 86% completed the 2-year trial, at which time, the mean (±SE) weight loss with usual care, brief lifestyle counseling, and enhanced brief lifestyle counseling was 1.7±0.7, 2.9±0.7, and 4.6±0.7 kg, respectively. Initial weight decreased at least 5% in 21.5%, 26.0%, and 34.9% of the participants in the three groups, respectively. Enhanced lifestyle counseling was superior to usual care on both these measures of success (P=0.003 and P=0.02, respectively), with no other significant differences among the groups. The benefits of enhanced lifestyle counseling remained even after participants given sibutramine were excluded from the analyses. There were no significant differences between the intervention groups in the occurrence of serious adverse events. CONCLUSIONS: Enhanced weight-loss counseling helps about one third of obese patients achieve long-term, clinically meaningful weight loss. (Funded by the National Heart, Lung, and Blood Institute; POWER-UP ClinicalTrials.gov number, NCT00826774.).

OBJECTIVE: Despite the increased emphasis on obesity and diet-related diseases, nutrition education remains lacking in many internal medicine training programs. We evaluated the attitudes, self-perceived proficiency, and knowledge related to clinical nutrition among a cohort of internal medicine interns. METHODS: Nutrition attitudes and self-perceived proficiency were measured using previously validated questionnaires. Knowledge was assessed with a multiple-choice quiz. Subjects were asked whether they had prior nutrition training. RESULTS: Of the 114 participants, 61 (54%) completed the survey. Although 77% agreed that nutrition assessment should be included in routine primary care visits, and 94% agreed that it was their obligation to discuss nutrition with patients, only 14% felt physicians were adequately trained to provide nutrition counseling. There was no correlation among attitudes, self-perceived proficiency, or knowledge. Interns previously exposed to nutrition education reported more negative attitudes toward physician self-efficacy (p = 0.03). CONCLUSIONS: Internal medicine interns' perceive nutrition counseling as a priority, but lack the confidence and knowledge to effectively provide adequate nutrition education.

Bariatric surgery leads to substantial and durable weight reduction. Nearly 30% of patients who undergo bariatric surgery have type 2 diabetes, and for many of them, diabetes resolves after surgery (84% to 98% for bypass procedures and 48% to 68% for restrictive procedures). Glycemic control improves in part because of caloric restriction but also because gut peptide secretion changes. Gut peptides, which mediate the enteroinsular axis, include the incretins glucagon-like peptide-1 and glucose-dependent insulinotropic peptide, as well as ghrelin and peptide YY. Bariatric surgery (particularly bypass procedures) alters secretion of these gut hormones, which results in enhanced insulin secretion and sensitivity. This review discusses the various bariatric procedures and how they alter the enteroinsular axis. Familiarity with these effects can help physicians decide among the different surgical procedures and avoid postoperative hypoglycemia.

Low-carbohydrate diets have been associated with significant reductions in weight and HbA(1c) in obese, diabetic participants who received high-intensity lifestyle modification for 6 or 12 months. This investigation sought to determine whether comparable results to those of short-term, intensive interventions could be achieved over a 24-month study period using a low-intensity intervention that approximates what is feasible in outpatient practice. A total of 144 obese, diabetic participants were randomly assigned to a low-carbohydrate diet (<30 g/day) or to a low fat diet (<or=30% of calories from fat with a deficit of 500 kcal/day). Participants were provided weekly group nutrition education sessions for the first month, and monthly sessions thereafter through the end of 24 months. Weight, HbA(1c), glucose, and lipids were measured at baseline and 6, 12, and 24 months. Of the 144 enrolled participants, 68 returned for the month 24 assessment visit. Weights were retrieved from electronic medical records for an additional 57 participants (total, 125 participants) at month 24. All participants with a baseline measurement and at least one of the three other measurements were included in the mixed-model analyses (n = 138). The low-intensity intervention resulted in modest weight loss in both groups at month 24. At this time, participants in the low-carbohydrate group lost 1.5 kg, compared to 0.2 kg in the low-fat group (P = 0.147). Lipids, glycemic indexes, and dietary intake did not differ between groups at month 24 (or at months 6 or 12) (ClinicalTrials.gov number, NCT00108459).