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1/03/2019

Behavioral weight loss programs are effective

Growing up I had to wear glasses. Back then it was considered socially unacceptable, but necessary to be able to see. Sixty years later, everyone wears glasses and they are a fashion statement. Now as an aging adult, I need to wear hearing aids. This was and still is in many age groups considered socially unacceptable — a sign of being old and maybe a little senile. But it appears that hearing aids are in the process of a similar transformation. A pared down, more affordable category of products — personal sound amplification products (PSAPs) — may lead to greater use of hearing enhancers at a younger age.
Hearing aids: Enhanced hearing, at a price

One of the major complaints about hearing aids is that they are expensive; they can run from $1,000 to $6,000 apiece. Their average lifespan is about five years, making this a recurring expense. Not everyone can afford or wishes to spend that amount to improve their hearing, especially if their hearing loss is mild and they can get by without aids.

There is a large segment of the population that has such a mild hearing loss. They struggle in certain situations, such as when there is a lot of background noise — in noisy restaurants, large crowds, and large rooms. They do fine in quiet situations with small groups or one-on-one conversation. They could benefit from “readers” for the ears — inexpensive help that they can use occasionally, or even continuously, for a little boost.

Until recently, the laws have been a barrier for development of such help. Hearing aids have been defined by law and regulated. High certification costs have served as a barrier to market entry. Hearing aid prices have not come down much over the years, though the quality of the aids and the sophistication of the instruments have improved as fast as any electronic device available. What you get now for the same price you would have paid 10 years ago is a far superior device. What’s more, the cost to dispense, service, and maintain the devices has increased with the cost of living. All of this has led to a gap between the demand for and supply of inexpensive hearing aids.
PSAPs: A more affordable option

Along come PSAPs, which have the potential to fill a large gap in the existing hearing aid product offerings. They provide a lesser certified, less feature-filled, but lower-cost entry for hearing loss sufferers. PSAPs cannot be called or marketed as “hearing aids,” as they do not meet the definition and rigorous manufacturing and safety standards of hearing aids.

PSAPs range from simple volume amplification devices to more sophisticated devices that can do many of the simpler tasks that hearing aids can perform. They are self-fitting and can be self-programmed using a smartphone or computer app. They are sold over the counter, and thus eliminate the expense of fitting. They are not as electronically sophisticated as hearing aids, and so can be sold cheaper. Lowering the cost of entry will allow most people to enjoy better hearing at a younger age.

PSAPs are not a replacement for hearing aids. They cannot replace the sophistication of hearing aids, or the skill in fitting them that audiologists bring to the job. They are devices that can fill the need for those with mild hearing loss, who just need a little more volume in certain situations. The good ones — the ones you should try — will be marketed as hearing aids in the near future.
Getting started with your PSAP

Suppose you want to try a PSAP. How do you know you are getting what you are being told you are getting? How do you know that what these products advertise is actually what they deliver? How do you know that they are safe? The FDA has stepped in to regulate this new market. Legislation was passed in 2017 and goes into effect in 2020 to allow for marketing of these low-end hearing aids to be advertised as such, if they meet certain (still-to-be finalized) criteria on performance and safety. Many of the devices are on the market today without any such oversight. That will change in 2020 to allow those devices that meet the established criteria to be marketed as hearing aids and not PSAPs.

Many of the new devices require some sophistication in setup and maintenance. You become the dispenser, fitter, and maintainer of the devices. You provide yourself with the services that an audiologist provides for hearing aids. YouTube videos and online support can resolve most if not all issues that may come up. Mandated trial periods can allow for return of goods when the issues cannot be resolved.
Better hearing, younger

In countries where hearing aids are free, more than half of the people who could use hearing aids do not use them. Money is clearly not the only issue preventing hearing aid use. Starting people earlier in the process and giving them control over the use of such devices can only encourage a greater long-term acceptance and usage of hearing aids as we age. Having more people use the devices eliminates the social stigma that has surrounded hearing aids.

I am hopeful that PSAPs are the intermediate steps that will lead to greater hearing aid use for the majority of us who should be using hearing aids, but do not. It’s a gorgeous weekend and you are playing a game of basketball with friends. You take a jump shot, scoring two points, but twist your right ankle on landing. You feel immediate pain and stop playing. After resting for an hour, you notice increased swelling and are having difficulty walking, so you go to the nearby urgent care center. The physician comes to see you, introduces herself, then introduces the medical scribe, who moves to the corner of the room in front of the computer. As the doctor starts asking you questions, the scribe begins typing.

Scribes are becoming increasingly common in doctor’s offices. But what do they do, what type of training do they have, and why are they gaining in popularity?
What are medical scribes?

Scribes are assistants to physicians and other healthcare providers. Their roles include entering electronic documentation (notes) into the computer, including patient history, physician examination findings, test results, and other information pertinent to your care. While the scribe’s primary role is to enter medical documentation, they may also check for test results and assist with assigning diagnoses and billing. The physician is then responsible for carefully reviewing the scribe’s notes, correcting any misinformation or omissions, and signing the notes.

Scribes are often college students or recent college graduates seeking additional exposure to the healthcare field before applying to medical school or other graduate training programs; however, scribing can also be a full-time career. They receive training on how to document as well as on medical coding and billing rules. In general, scribes do not have healthcare provider training or certification. Unless your scribe is also a nurse, medical assistant, or other certified medical professional, they should not be providing medical advice or delivering care to you.

Scribes are members of the healthcare delivery team, and are therefore accountable to all applicable institutional policies and are expected to act professionally. For example, scribes are held to the same standards to protect patient privacy as other health care professionals. Scribes should be introduced to the patient when they enter the room. If you are uncomfortable with a scribe being present during your visit, you should request to be seen by the healthcare provider privately.
Why are scribes gaining popularity?

The practice of medicine requires a large number of administrative tasks, including thorough documentation of all patient visits. As the majority of US hospitals and physician offices have now transitioned to electronic documentation, physicians are spending an increasing amount of time on the computer instead of with the patient.

Adding a scribe to the team enables physicians to spend more time directly talking with patients, while the scribe documents the visit. Scribes are being used in all care settings, including the primary care office, specialist offices, urgent care, emergency departments, and inpatient hospitals. A recent study in the primary care setting found reductions in the amount of time spent with electronic documentation and improvements in physician productivity and work satisfaction associated with the use of medical scribes.
The future of scribes

Today, scribes typically accompany the physician and patient in the room. In-person scribes are also being supplemented by virtual scribes, where the scribe is not physically present in the room with the patient. For example, physicians may use a recording device to capture their interview and examination of the patient. The electronic recording can then be sent to the scribes (who are offsite), and then transcribed and entered into the computer. Newer video teleconferencing software and smart glasses are also being used to allow the scribe to view and transcribe the visit into the computer from an offsite location. The latter technology has the benefit of allowing the scribe to work in real time, asking clarifying questions to the providers, and entering the notes faster. Importantly, with both these scenarios, physicians are still responsible for the content of the notes and must review and sign off on the notes.

The US Centers for Medicaid and Medicare Services, which oversees federal health insurance programs, is currently working to reduce documentation requirements for billing, which may help decrease physician workload. In addition, advances in technology may one day completely automate documentation of patient visits.

In the meantime, scribes provide the ability for physicians to focus more on the patient relationship and interaction and less on computer data entry. The US Preventive Services Task Force (USPSTF) is a team of volunteer experts from various primary care medicine and nursing fields. They identify big medical problems, review the research, and translate it into action plans (called practice recommendations) for doctors like me.

Just this fall, they tackled obesity, with the goal of identifying effective ways we in primary care can help people to lose weight.

And it’s not about aesthetics. This is about disease prevention, especially diabetes, high blood pressure, and heart disease, which are particularly associated with obesity.

They were NOT looking at surgeries or other procedures, only research trials involving either behavioral or medication-based weight loss programs.

The task force analyzed 89 behavioral weight loss program trials from all over the world, and these included participants of both genders as well as many racial and ethnic groups, with ages between 22 and 66, and body mass index between 25 and 39.
What was involved in a behavioral weight loss program?

The programs studied lasted between 12 and 24 months, and involved at least 12 sessions (face-to-face, group meetings, or web-based). A variety of specialists were involved (behavioral therapists, psychologists, registered dietitians, exercise physiologists, lifestyle coaches, as well as physicians) who provided counseling on basics like nutrition, physical activity, and self-monitoring, as well as psychological components like identifying obstacles, planning ahead, problem solving, and relapse prevention. Email, telephone, and/or peer support were typically included. Basically, these are intensive programs that focus on lasting diet and lifestyle change.

And intensive diet and lifestyle programs work well for weight loss. Participants had significant weight loss compared to controls, averaging between 1 and 20 pounds, with an average weight loss of 5 pounds overall, and were more likely to have lost 5% of their total body weight at 12 to 18 months. Thirteen trials looked at diabetes risk, and pooled results showed that participants had a significantly lower risk of developing diabetes.

Here’s the most important part: the risks of participating in these studies were minimal. This is a major plus to behavioral interventions: no side effects or drug complications.
How did behavioral programs compare with medications?

That is considerably different from studies featuring weight loss medications. Thirty-five studies looking at a variety of medications (like liraglutide, lorcaserin, naltrexone and bupropion, orlistat, and phentermine-topiramate) had stringent inclusion criteria and high dropout rates. Why? Because of the many medical contraindications of some of these medications, and the side effects, some quite serious.

Yes, the medication studies demonstrated significant weight loss, ranging from 2 to 13 pounds. But in the end, the USPSTF has to weigh effectiveness as well as potential risks, and they concluded that “intensive, multicomponent behavioral interventions in adults with obesity can lead to clinically significant improvements in weight status and reduce the incidence of type 2 diabetes among adults with obesity and elevated plasma glucose levels …[]… and that the harms of intensive, multicomponent behavioral interventions (including weight loss maintenance interventions) in adults with obesity are small to none.”

Basically, intensive behavioral programs aimed at lasting lifestyle changes work well for weight loss, and are extremely low-risk to boot.
So where can you sign up for such programs?

Okay, here’s where the gap between science and practice comes in.

Few of these behavioral weight loss programs exist, and not everyone meets the criteria for insurance to cover them. So for most people, unless they can afford to pay out of pocket, these programs are only available through research studies.

For example, the Diabetes Prevention Program (DPP) is an excellent intensive lifestyle change behavioral weight loss program that has been studied for literally decades and works very well. It’s a year-long commitment including 22 learning sessions (in-person or online) and frequent contact with a lifestyle coach. Insurance will cover this program for people who have a BMI over 25 and a confirmed diagnosis of prediabetes. Not diabetes, only prediabetes. The DPP curriculum is available for free on the Centers for Disease Control (CDC) website. Anyone could establish a program.

But a program has to meet a lot of requirements over a significant amount of time before it’s officially recognized by the CDC, and insurance companies won’t cover a program until it’s recognized by the CDC. Even then, reimbursement rates can vary. As a result, there aren’t many of these programs up and running, but there are some. To find a recognized DPP program in your state or online, check out the CDC’s registry.

Many hospitals offer less intensive, shorter behavioral lifestyle change programs, but these are pay-out-of-pocket and generally cost upwards of $500.
What can you do if you can’t access a behavioral weight loss program?

You can work with your doctor and create your own program by consulting with relevant specialists (for example, a nutritionist, personal trainer, and therapist), following your own progress (for example, at the doctor’s office or using an app), and arranging your own peer support (ask friends and family to join you on your health journey, or join a group like Weight Watchers). I have had patients who have succeeded in making lasting lifestyle changes — including weight loss — using this approach.

Mobile phone apps are a relatively new but promising tool. In one 2015 research review, studies of various weight loss phone apps, used for six weeks to nine months, showed a significant average weight loss of 2.2 pounds. Some free, widely available apps include MyFitnessPal, Lose It, Noom, Weight Watchers, and Fooducate (note that these were not necessarily the ones studied in that review article).

I am hopeful that soon, guidelines-based intensive lifestyle change programs will become more widely accessible to everyone who needs this support.

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