Screening and brief intervention for obesity in primary care: cost-effectiveness analysis in the BWeL trial.

BACKGROUND: The Brief Intervention for Weight Loss Trial enrolled 1882 consecutively attending primary care patients who were obese and participants were randomised to physicians opportunistically endorsing, offering, and facilitating a referral to a weight loss programme (support) or recommending weight loss (advice). After one year, the support group lost 1.4 kg more (95%CI 0.9 to 2.0): 2.4 kg versus 1.0 kg. We use a cohort simulation to predict effects on disease incidence, quality of life, and healthcare costs over 20 years. METHODS: Randomly sampling from the trial population, we created a virtual cohort of 20 million adults and assigned baseline morbidity. We applied the weight loss observed in the trial and assumed weight regain over four years. Using epidemiological data, we assigned the incidence of 12 weight-related diseases depending on baseline disease status, age, gender, body mass index. From a healthcare perspective, we calculated the quality adjusted life years (QALYs) accruing and calculated the incremental difference between trial arms in costs expended in delivering the intervention and healthcare costs accruing. We discounted future costs and benefits at 1.5% over 20 years. RESULTS: Compared with advice, the support intervention reduced the cumulative incidence of weight-related disease by 722/100,000 people, 0.33% of all weight-related disease. The incremental cost of support over advice was £2.01million/100,000. However, the support intervention reduced health service costs by £5.86 million/100,000 leading to a net saving of £3.85 million/100,000. The support intervention produced 992 QALYs/100,000 people relative to advice. CONCLUSIONS: A brief intervention in which physicians opportunistically endorse, offer, and facilitate a referral to a behavioural weight management service to patients with a BMI of at least 30 kg/m2 reduces healthcare costs and improves health more than advising weight loss.

Doctor Referral of Overweight People to Low Energy total diet replacement Treatment (DROPLET): pragmatic randomised controlled trial.

OBJECTIVE: To test the effectiveness and safety of a total diet replacement (TDR) programme for routine treatment of obesity in a primary care setting. DESIGN: Pragmatic, two arm, parallel group, open label, individually randomised controlled trial. SETTING: 10 primary care practices in Oxfordshire, UK. PARTICIPANTS: 278 adults who were obese and seeking support to lose weight: 138 were assigned to the TDR programme and 140 to usual care. 73% of participants were re-measured at 12 months. INTERVENTIONS: The TDR programme comprised weekly behavioural support for 12 weeks and monthly support for three months, with formula food products providing 810 kcal/day (3389 kJ/day) as the sole food during the first eight weeks followed by reintroduction of food. Usual care comprised behavioural support for weight loss from a practice nurse and a diet programme with modest energy restriction. MAIN OUTCOME MEASURES: The primary outcome was weight change at 12 months analysed as intention to treat with mixed effects models. Secondary outcomes included biomarkers of cardiovascular and metabolic risk. Adverse events were recorded. RESULTS: Participants in the TDR group lost more weight (-10.7 kg) than those in the usual care group (-3.1 kg): adjusted mean difference -7.2 kg (95% confidence interval -9.4 to -4.9 kg). 45% of participants in the TDR group and 15% in the usual care group experienced weight losses of 10% or more. The TDR group showed greater improvements in biomarkers of cardiovascular and metabolic risk than the usual care group. 11% of participants in the TDR group and 12% in the usual care group experienced adverse events of moderate or greater severity. CONCLUSIONS: Compared with regular weight loss support from a practice nurse, a programme of weekly behavioural support and total diet replacement providing 810 kcal/day seems to be tolerable, and leads to substantially greater weight loss and greater improvements in the risk of cardiometabolic disease. TRIAL REGISTRATION: International Standard Randomised Controlled Trials No ISRCTN75092026.

Screening and brief intervention for obesity in primary care: a parallel, two-arm, randomised trial.

BACKGROUND: Obesity is a common cause of non-communicable disease. Guidelines recommend that physicians screen and offer brief advice to motivate weight loss through referral to behavioural weight loss programmes. However, physicians rarely intervene and no trials have been done on the subject. We did this trial to establish whether physician brief intervention is acceptable and effective for reducing bodyweight in patients with obesity. METHODS: In this parallel, two-arm, randomised trial, patients who consulted 137 primary care physicians in England were screened for obesity. Individuals could be enrolled if they were aged at least 18 years, had a body-mass index of at least 30 kg/m2 (or at least 25 kg/m2 if of Asian ethnicity), and had a raised body fat percentage. At the end of the consultation, the physician randomly assigned participants (1:1) to one of two 30 s interventions. Randomisation was done via preprepared randomisation cards labelled with a code representing the allocation, which were placed in opaque sealed envelopes and given to physicians to open at the time of treatment assignment. In the active intervention, the physician offered referral to a weight management group (12 sessions of 1 h each, once per week) and, if the referral was accepted, the physician ensured the patient made an appointment and offered follow-up. In the control intervention, the physician advised the patient that their health would benefit from weight loss. The primary outcome was weight change at 12 months in the intention-to-treat population, which was assessed blinded to treatment allocation. We also assessed asked patients' about their feelings on discussing their weight when they have visited their general practitioner for other reasons. Given the nature of the intervention, we did not anticipate any adverse events in the usual sense, so safety outcomes were not assessed. This trial is registered with the ISRCTN Registry, number ISRCTN26563137. FINDINGS: Between June 4, 2013, and Dec 23, 2014, we screened 8403 patients, of whom 2728 (32%) were obese. Of these obese patients, 2256 (83%) agreed to participate and 1882 were eligible, enrolled, and included in the intention-to-treat analysis, with 940 individuals in the support group and 942 individuals in the advice group. 722 (77%) individuals assigned to the support intervention agreed to attend the weight management group and 379 (40%) of these individuals attended, compared with 82 (9%) participants who were allocated the advice intervention. In the entire study population, mean weight change at 12 months was 2·43 kg with the support intervention and 1·04 kg with the advice intervention, giving an adjusted difference of 1·43 kg (95% CI 0·89-1·97). The reactions of the patients to the general practitioners' brief interventions did not differ significantly between the study groups in terms of appropriateness (adjusted odds ratio 0·89, 95% CI 0·75-1·07, p=0·21) or helpfulness (1·05, 0·89-1·26, p=0·54); overall, four (<1%) patients thought their intervention was inappropriate and unhelpful and 1530 (81%) patients thought it was appropriate and helpful. INTERPRETATION: A behaviourally-informed, very brief, physician-delivered opportunistic intervention is acceptable to patients and an effective way to reduce population mean weight. FUNDING: The UK National Prevention Research Initiative.

Exploratory behavior in mice selectively bred for developmental differences in aggressive behavior.

The development and expression of exploratory behavior was assessed in the Cairns lines of Institute for Cancer Research (ICR) mice that were selectively bred for differences in aggressive behavior, with a high-aggressive 900 line, low-aggressive 100 line, and control 500 line. Four paradigms were employed. Developmental changes were evident in the complex novel arena, with older males faster to contact a novel object, and ambulating more than young males. Within the control 500 line, older males showed longer latency to emerge from the home cage, and shorter latency to contact novel objects. In the 900 line, younger males showed this same pattern. R. B. Cairns proposed that line differences in aggressive behavior arise through alterations in developmental timing [Cairns et al. [1983] Life-span developmental psychology (Vol. 5). New York: Academic Press; Gariépy et al. [2001] Animal Behaviour 61: 933-947]. The early appearance of mature patterns of exploratory behavior in 900 line males supports this interpretation. The 900 line males also appear to be behaviorally inhibited in novel settings such as the light-dark box and the neohypophagia paradigm, compared to the 500 and 100 lines (Experiments 1, 2, and 4). Moreover, in the most complex apparatus, the novel arena, 900 line males were slowest to exit the home cage, and fastest to contact a novel object. The apparent contrast in these parameters of exploratory behavior is discussed in relation to T. C. Schneirla's [1965 Advances in the study of behavior (Vol. 1). New York: PN Academic] approach-withdrawal theory.

Maternal behavior changes after immune challenge of neonates with developmental effects on adult social behavior.

To examine whether maternal responsiveness during interactions with endotoxin-treated pups contributes to long-term effects on social development, neonatal mice were fostered on postnatal day 1 to dams from three selectively bred lines that differ in social behaviors. On day 5, neonates were administered saline or 0.5 mg/kg endotoxin (lipopolysaccharide, i.p.). Observations of undisturbed dams and litters on days 2, 4, 6, and 8 showed modest line differences in maternal behaviors. At the peak intensity of the transient illness induced by endotoxin (3 hr postinjection on day 5), dams increased licking and decreased time off-nest for endotoxin, but not saline-treated pups. As adults, fostered-reared males were observed in brief social interactions. Males exposed to endotoxin early in life showed changes in adult social behaviors that depended on foster dam line as well as individual differences in maternal responsiveness. Maternal responsiveness to stressed neonates can ameliorate the social-developmental effects of early illness.