MNT: Weight Management (2015)
Welty FK, Nasca MM, Lew NS, Gregoire S, Ruan Y. Effect of onsite dietitian counseling on weight loss and lipid levels in an outpatient physician office. Am J Cardiol. 2007; 100(1): 73-75.PubMed ID: 17599444
To examine the effect of an outpatient-based diet and exercise counseling program on weight loss and lipid levels with an onsite dietitian who sees patients at the same visit with the physician and is fully reimbursable.
- Overweight or obese patients
- With one or more cardiovascular risk factors (86%) or coronary heart disease (14%).
None specifically mentioned.
Patients were seen at the initial visit with one provider, a preventive cardiologist and a dietitian at the Cardiovascular Health and Lipid Center at Beth Israel Deaconess Medical Center from 2000 to 2004. More than 90% had been referred by their primary care physician for management of hyperlipidemia and weight management. Remaining patients were self-referred.
Time series study.
- Subjects were counseled to exercise 30 minutes a day and eat a modified Dietary Approaches to Stop Hypertension (DASH) diet (saturated fat less than 7%, polyunsaturated fat to 10%, monounsaturated fat to 18%, low in glycemic index and sodium and high in fiber, low-fat dairy products, fruits and vegetables). Caloric decrease was recommended when indicated.
- The dietitian spent 45 to 60 minutes at the initial visit and 15 to 30 minutes at follow-up visits
- Behavioral and exercise counseling was completed by the physician.
Timing of Measurements
Outcomes were measured at one concurrent follow-up visit with the dietitian and physician and more than one additional follow-up with the physician.
- Weight, height, BMI
- Lipid levels
- Blood pressure.
Exercise and DASH diet.
- Initial N: Assumed 80 subjects
- Attrition (final N): 80 subjects
- Age: Mean age 55±12 years
- Other relevant demographics: Baseline BMI, 30.1±6.4
- Location: Massachusetts.
Maximum weight lost was an average of 5.6% (10.8 lb) at a mean follow-up of 1.75 years.
64 (81%) of these patients maintained significant weight loss (mean 5.3%) at a mean follow-up of 2.6 years.
Average weight regain was only 0.3% of the maximum weight loss for most patients.
Weight regain for all 80 patients was 1.6% at an average follow-up of 2.6 years.
Average decrease in LDL-cholesterol was 9.3% (from 142±30 to 129.0±26mg per dL), average decrease in triglycerides was 34% (from 297±105 to 196±67mg per dL), and average increase in HDL-cholesterol was 9.6% (from 48±9 to 53±13mg per dL).
Systolic blood pressure was lowered from 129 to 126mm Hg (P=0.21) and diastolic blood pressure from 79 to 75mm Hg (P=0.003).
In conclusion, having a dietitian counsel patients concurrently with a physician in the outpatient setting is effective in achieving and maintaining weight loss and is fully reimbursable.
Initial N assumed to be 80 subjects. Physicians responsible for both behavioral and exercise counseling. Measurements of outcome variables and compliance with dietary intervention not described. Statistical analysis not described; many results reported without statistical significance. Authors note the strength of the study is the significant weight loss and its long-term maintenance, but no limitations.
Quality Criteria Checklist: Primary Research
|1.||Would implementing the studied intervention or procedure (if found successful) result in improved outcomes for the patients/clients/population group? (Not Applicable for some epidemiological studies)||Yes|
|2.||Did the authors study an outcome (dependent variable) or topic that the patients/clients/population group would care about?||Yes|
|3.||Is the focus of the intervention or procedure (independent variable) or topic of study a common issue of concern to dieteticspractice?||Yes|
|4.||Is the intervention or procedure feasible? (NA for some epidemiological studies)||Yes|
|1.||Was the research question clearly stated?||Yes|
|1.1.||Was (were) the specific intervention(s) or procedure(s) [independent variable(s)] identified?||Yes|
|1.2.||Was (were) the outcome(s) [dependent variable(s)] clearly indicated?||Yes|
|1.3.||Were the target population and setting specified?||Yes|
|2.||Was the selection of study subjects/patients free from bias?||Yes|
|2.1.||Were inclusion/exclusion criteria specified (e.g., risk, point in disease progression, diagnostic or prognosis criteria), and with sufficient detail and without omitting criteria critical to the study?||Yes|
|2.2.||Were criteria applied equally to all study groups?||Yes|
|2.3.||Were health, demographics, and other characteristics of subjects described?||Yes|
|2.4.||Were the subjects/patients a representative sample of the relevant population?||Yes|
|3.||Were study groups comparable?||N/A|
|3.1.||Was the method of assigning subjects/patients to groups described and unbiased? (Method of randomization identified if RCT)||N/A|
|3.2.||Were distribution of disease status, prognostic factors, and other factors (e.g., demographics) similar across study groups at baseline?||N/A|
|3.3.||Were concurrent controls or comparisons used? (Concurrent preferred over historical control or comparison groups.)||N/A|
|3.4.||If cohort study or cross-sectional study, were groups comparable on important confounding factors and/or were preexisting differences accounted for by using appropriate adjustments in statistical analysis?||N/A|
|3.5.||If case control study, were potential confounding factors comparable for cases and controls? (If case series or trial with subjects serving as own control, this criterion is not applicable.)||N/A|
|3.6.||If diagnostic test, was there an independent blind comparison with an appropriate reference standard (e.g., "gold standard")?||N/A|
|4.||Was method of handling withdrawals described?||???|
|4.1.||Were follow-up methods described and the same for all groups?||???|
|4.2.||Was the number, characteristics of withdrawals (i.e., dropouts, lost to follow up, attrition rate) and/or response rate (cross-sectional studies) described for each group? (Follow up goal for a strong study is 80%.)||???|
|4.3.||Were all enrolled subjects/patients (in the original sample) accounted for?||???|
|4.4.||Were reasons for withdrawals similar across groups?||???|
|4.5.||If diagnostic test, was decision to perform reference test not dependent on results of test under study?||N/A|
|5.||Was blinding used to prevent introduction of bias?||Yes|
|5.1.||In intervention study, were subjects, clinicians/practitioners, and investigators blinded to treatment group, as appropriate?||N/A|
|5.2.||Were data collectors blinded for outcomes assessment? (If outcome is measured using an objective test, such as a lab value, this criterion is assumed to be met.)||Yes|
|5.3.||In cohort study or cross-sectional study, were measurements of outcomes and risk factors blinded?||N/A|
|5.4.||In case control study, was case definition explicit and case ascertainment not influenced by exposure status?||N/A|
|5.5.||In diagnostic study, were test results blinded to patient history and other test results?||N/A|
|6.||Were intervention/therapeutic regimens/exposure factor or procedure and any comparison(s) described in detail? Were interveningfactors described?||Yes|
|6.1.||In RCT or other intervention trial, were protocols described for all regimens studied?||Yes|
|6.2.||In observational study, were interventions, study settings, and clinicians/provider described?||N/A|
|6.3.||Was the intensity and duration of the intervention or exposure factor sufficient to produce a meaningful effect?||Yes|
|6.4.||Was the amount of exposure and, if relevant, subject/patient compliance measured?||Yes|
|6.5.||Were co-interventions (e.g., ancillary treatments, other therapies) described?||Yes|
|6.6.||Were extra or unplanned treatments described?||N/A|
|6.7.||Was the information for 6.4, 6.5, and 6.6 assessed the same way for all groups?||N/A|
|6.8.||In diagnostic study, were details of test administration and replication sufficient?||N/A|
|7.||Were outcomes clearly defined and the measurements valid and reliable?||???|
|7.1.||Were primary and secondary endpoints described and relevant to the question?||Yes|
|7.2.||Were nutrition measures appropriate to question and outcomes of concern?||Yes|
|7.3.||Was the period of follow-up long enough for important outcome(s) to occur?||Yes|
|7.4.||Were the observations and measurements based on standard, valid, and reliable data collection instruments/tests/procedures?||???|
|7.5.||Was the measurement of effect at an appropriate level of precision?||???|
|7.6.||Were other factors accounted for (measured) that could affect outcomes?||Yes|
|7.7.||Were the measurements conducted consistently across groups?||N/A|
|8.||Was the statistical analysis appropriate for the study design and type of outcome indicators?||No|
|8.1.||Were statistical analyses adequately described and the results reported appropriately?||No|
|8.2.||Were correct statistical tests used and assumptions of test not violated?||???|
|8.3.||Were statistics reported with levels of significance and/or confidence intervals?||No|
|8.4.||Was "intent to treat" analysis of outcomes done (and as appropriate, was there an analysis of outcomes for those maximally exposed or a dose-response analysis)?||N/A|
|8.5.||Were adequate adjustments made for effects of confounding factors that might have affected the outcomes (e.g., multivariate analyses)?||???|
|8.6.||Was clinical significance as well as statistical significance reported?||Yes|
|8.7.||If negative findings, was a power calculation reported to address type 2 error?||N/A|
|9.||Are conclusions supported by results with biases and limitations taken into consideration?||Yes|
|9.1.||Is there a discussion of findings?||Yes|
|9.2.||Are biases and study limitations identified and discussed?||No|
|10.||Is bias due to study's funding or sponsorship unlikely?||Yes|
|10.1.||Were sources of funding and investigators' affiliations described?||Yes|
|10.2.||Was the study free from apparent conflict of interest?||Yes|