The Problem

A 56-year-old woman presents to you for peripheral edema. She has a history of asthma, diabetes mellitus type 2 on insulin, hypertension, and sleep apnea. She has a sedentary job and does not routinely exercise. She has a body mass index of 55 kg/m² and 1+ pitting pedal edema with an otherwise normal examination. She reports that she has not been adherent with her CPAP because of a poorly fitting mask. You set her up for mask refitting and recommend compression stockings and exercise. She contacts you 3 months later to tell you that she has been adherent with CPAP and compression stockings, and the peripheral edema has improved. She has been less fatigued and exercises more but has been frustrated by her inability to lose weight. She was deterred from bariatric surgery after taking the classes and quit orlistat due to side effects associated with dietary indiscretions. Her insurance will not cover sibutramine, and she does not want to pay for it out of pocket. In desperation, you search PubMed to see what nonpharmacologic interventions have demonstrated benefit for facilitating weight loss.

The Question

In patients with obesity, what nonpharmacologic interventions are effective for weight loss?

The Search

You log on to PubMed (www.pubmed.gov), search for “obesity,” and limit the results to “randomized controlled trials.” You find a relevant study. (See below.)

Our Critique

Watching television is the third most time-consuming activity for American adults after work and sleep. We were amazed to learn that the average U.S. adult watches 5 hours of TV per day and will spend more than 65 days in total hours in front of the TV over the course of a year. The authors point out that the short duration of the study may not have captured stabilization of behaviors, which may have increased observed differences between the two groups. Interestingly, TV viewing time also decreased in the control group, which may have been related to either seasonal variation (i.e., less TV in the summer) or the Hawthorne effect (i.e., being observed changes behavior). This was a well-conducted trial providing us with a practical and useful intervention to present to patients asking that we “fix” their obesity. Counseling overweight and obese patients on the positive impact of turning off the TV adds to our armamentarium facilitating transference of the “locus of control” back to the patient.

Clinical Decision

Upon further history taking, you discover that the patient watches about 4 hours of reality TV per day. You share the findings from the study with her and recommend that she decrease television consumption by 50%. She tells you that she is not certain that she can do this with the season finale of “The Amazing Race” coming up, and requests that you get back to her if you discover any other new ideas.

The Evidence

Otten J.J., et al. Effects of television viewing reduction on energy intake and expenditure in overweight and obese adults. Arch. Intern. Med. 2009;169:2109-15.

–Design and setting: Randomized clinical trial done in Vermont.

–Patients: Patients were eligible for enrollment if they had a BMI of 25-50, were aged 21-65 years, and reported watching television for 3-8 hours/day. Potential subjects were excluded if they had factors conflicting with study outcomes (e.g., pregnancy/breastfeeding, certain medications, or participation in another intervention related to energy balance or sleep), reasons rendering TV lockout impractical, conflicts interfering with the study, medical or pharmaceutical contraindications, or household members not agreeing to the intervention.

–Intervention: After a 3-week observation-only period (phase 1), subjects were randomized (phase 2) to either a 3-week TV reduction intervention or to an observation-only control group. The intervention consisted of reducing TV viewing by 50% from each participant’s objectively measured phase 1 viewing time. Baseline TV viewing was assessed using electronic monitors (BOB TV Time Manager by Hopscotch Technology).

–Outcomes: Outcomes were energy expenditure (EE), energy intake (EI), weight, and sleep. EE was measured using a portable device (SenseWear Pro 3 Armband by Bodymedia). Sleep was measured using logs, and diet information was collected through dietary recalls administered by telephone.

–Results: No significant differences were observed between groups at baseline. Eleven men and 25 women aged 22-61 years were randomized to intervention (n = 20) or control (n = 16) groups. Daily TV viewing (mean, hours/day) decreased by more than the 50% goal in the intervention group (4.8 hours in phase 1 vs. 1.8 hours in phase 2). However, the control group also decreased their TV viewing (5.3 hours in phase 2 to 4.5 hours in phase 2). No significant differences were observed in EI between groups. Subjects in the intervention group significantly increased EE, compared with controls (119 vs. –95 kcal/day). The intervention group had a significant decrease in time spent in sedentary activities, compared with a nonsignificant increase in controls. The intervention group had a negative energy balance between phases (–244 kcal/day), compared with a positive energy balance for the control groups (57 kcal/day). The intervention group had a greater decrease in BMI (–0.25 vs. –0.06 kg/m²). Minimal change was observed in total sleep.

Dr. Ebbert and Dr. Tangalos write the “Mindful Practice” column, which regularly appears in Internal Medicine News, an Elsevier publication. They are with the Mayo Clinic in Rochester, Minn. They report no conflicts of interest.