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What’s the most effective way to screen patients with a family history of colon cancer?
THE BEST APPROACH HINGES on the number, degree, and age of relatives diagnosed with colorectal cancer (CRC) or adenomatous polyps (AP). Screening should begin at 40 years of age for patients with a family history of CRC or AP in at least 1 first-degree relative or CRC in at least 2 second-degree relatives (strength of recommendation [SOR]: B, extrapolation from systematic reviews).
Patients at highest risk—who have 1 first-degree relative diagnosed with CRC or AP before 60 years of age or multiple first-degree relatives diagnosed at any age—should begin screening with colonoscopy at 40 years of age or 10 years younger than the earliest affected relative and undergo a repeat colonoscopy every 5 years (SOR: C, consensus guidelines).
Patients who have a first-degree relative diagnosed with CRC or AP after 60 years of age or 2 or more second-degree relatives with CRC should start screening at 40 years of age, with routine options and follow-up intervals (SOR: C, consensus guidelines). (Routine options and follow-up intervals include any of the following 3 regimens: annual high-sensitivity fecal occult blood testing, sigmoidoscopy every 5 years combined with high-sensitivity fecal occult blood testing every 3 years, or screening colonoscopy every 10 years.1)
Evidence summary
Prospective studies and systematic reviews show increased risk for CRC in people with a significant family history. Little or no data are available regarding outcome improvements or head-to-head comparisons of the effects of different screening methods. Recommendations for screening rest largely on inference and consensus opinions.
Family history=higher risk at lower age
The US Preventive Services Task Force (USPSTF) recommends CRC screening starting at 50 years of age for patients with average risk, based on a 5.6% lifetime risk of developing CRC and good evidence that screening reduces morbidity and mortality.1 Patients with a family history of CRC or AP have a risk of CRC at 40 years of age that approximates average risk at 50 years.2 Right-sided colonic lesions are also more likely in patients with a family history of CRC (relative risk [RR]=2.25; 95% confidence interval [CI], 1.96-2.59).3
Risk increases with number of affected first-degree relatives
Moreover, systematic reviews show the RR of CRC to be 1.99 (95% CI, 1.55-2.55) in patients with a single first-degree relative with AP, 2.25 (95% CI, 2.00-2.53) with a single first-degree relative with CRC, and 4.25 (95% CI, 3.01-6.02) with 2 or more first-degree relatives with CRC.3
Younger age at diagnosis also increases risk
The effect of the relative’s age at diagnosis of CRC is demonstrated by an RR of 3.87 (95% CI, 2.40-6.22) if diagnosed at younger than 45 years, 2.25 (95% CI, 1.85-2.72) if diagnosed at 45 to 59 years, and 1.82 (95% CI, 1.47-2.25) if diagnosed at 60 years or older.3
Recommendations
Colonoscopy is the preferred screening option for most patients with family histories that put them at increased risk of CRC and right-sided colonic lesions.4,5 The American Cancer Society (ACS) and the American Gastroenterological Association (AGA) recommend that patients with a first-degree relative diagnosed before the age of 60 years or 2 or more first-degree relatives with CRC are at highest risk and should undergo colonoscopy at age 40, or 10 years before the earliest relative’s age at diagnosis; colonoscopy should be repeated every 5 years.4,5
Patients with a first-degree relative diagnosed with CRC or AP at 60 years or older or multiple second-degree relatives with CRC have an increased risk, but lower than the high-risk group.4 Such patients may start screening early, at 40 years, but using the same options as patients at average risk (see the Evidence-Based Answer).4 The TABLE summarizes these screening recommendations. Notably, the ACS recommends no screening change (from patients with average risk) for patients with CRC in second-degree relatives because of the modest increase in risk.5
TABLE
ACS and AGA guidelines for screening patients with a family history of colorectal cancer
| Risk factor | Screening method | Age to start | Surveillance |
|---|---|---|---|
| CRC or AP in 1 first-degree relative diagnosed at <60 yr or multiple first-degree relatives | Colonoscopy | 40 yr, or 10 yr before earliest age at diagnosis of an affected relative | Repeat every 5 years |
| 1 first-degree relative with CRC diagnosed at ≥60 yr or ≥2 second-degree relatives with CRC | Same as average-risk screening* | 40 yr | Same as average-risk screening |
| 1 second-degree or any more distant relatives with CRC | Same as average-risk screening | Same as average-risk screening | Same as average-risk screening |
| *The ACS recommends screening these patients as average risk, meaning that screening should occur at age 50 and can use other recommended screening methods besides colonoscopy. | |||
| ACS, American Cancer Society; AGA, American Gastroenterological Association; AP, adenomatous polyps; CRC, colorectal cancer. | |||
| Adapted from: Winawer S et al. Gastroenterology. 2003 and Smith RA et al. CA Cancer J Clin. 2003.5 | |||
The American Society for Gastrointestinal Endoscopy (ASGE) recommends screening colonoscopy for patients with a first-degree relative who was older than 60 when diagnosed with adenomas but notes that the timing of initial colonoscopy hasn’t been established and should be individualized. The interval for follow-up colonoscopy in these patients should be the same as for average-risk patients. Patients with a second- or third-degree relative with colonic neoplasia should adhere to average-risk screening recommendations.6 Otherwise, the ASGE recommendations agree with the ones described previously.
The most recent joint guidelines of the US Multisociety Task Force (USMSTF) on Colorectal Cancer, the American College of Radiology, and the ACS, released in 2008, make no recommendations regarding patients with a family history.7 The USMSTF defers to guidelines from the ACS and the AGA described earlier.
Acknowledgements
The opinions and assertions contained herein are the private views of the authors and not to be construed as official, or as reflecting the views of the US Air Force Medical Service or the US Air Force at large.
1. US Preventive Services Task Force. Screening for colorectal cancer. Rockville, MD: Agency for Healthcare Research and Quality; July 2002. Available at: www.ahrq.gov/clinic/uspstf/uspscolo.htm. Accessed June 11, 2008.
2. Fuchs CS, Giovannucci EL, Colditz GA, et al. A prospective study of family history and the risk of colorectal cancer. N Engl J Med. 1994;331:1669-1674.
3. Johns LE, Houlston RS. A systematic review and meta-analysis of familial colorectal cancer risk. Am J Gastroenterol. 2001;96:2992-3003.
4. Winawer S, Fletcher R, Rex D, et al. Colorectal cancer screening and surveillance: clinical guidelines and rationale—update based on new evidence. Gastroenterology. 2003;124:544-560.
5. Smith RA, Cokkinides V, Eyre HJ. American Cancer Society. American Cancer Society guidelines for the early detection of cancer, 2003. CA Cancer J Clin. 2003;53:27-43.Available at: http://caonline.amcancersoc.org/cgi/content/full/53/1/27. Accessed June 11, 2008.
6. Davila RE, Rajan E, Baron TH, et al. ASGE guideline: colorectal cancer screening and surveillance. Gastrointest Endosc. 2006;63:546-557.
7. Levin B, Lieberman DA, McFarland B, et al. Screening and surveillance for the early detection of colorectal cancer and adenomatous polyps, 2008: a joint guideline from the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology. CA Cancer J Clin. 2008;58:130-160.Available at: http://caonline.amcancersoc.org/cgi/content/full/58/3/130. Accessed on June 11, 2008.
THE BEST APPROACH HINGES on the number, degree, and age of relatives diagnosed with colorectal cancer (CRC) or adenomatous polyps (AP). Screening should begin at 40 years of age for patients with a family history of CRC or AP in at least 1 first-degree relative or CRC in at least 2 second-degree relatives (strength of recommendation [SOR]: B, extrapolation from systematic reviews).
Patients at highest risk—who have 1 first-degree relative diagnosed with CRC or AP before 60 years of age or multiple first-degree relatives diagnosed at any age—should begin screening with colonoscopy at 40 years of age or 10 years younger than the earliest affected relative and undergo a repeat colonoscopy every 5 years (SOR: C, consensus guidelines).
Patients who have a first-degree relative diagnosed with CRC or AP after 60 years of age or 2 or more second-degree relatives with CRC should start screening at 40 years of age, with routine options and follow-up intervals (SOR: C, consensus guidelines). (Routine options and follow-up intervals include any of the following 3 regimens: annual high-sensitivity fecal occult blood testing, sigmoidoscopy every 5 years combined with high-sensitivity fecal occult blood testing every 3 years, or screening colonoscopy every 10 years.1)
Evidence summary
Prospective studies and systematic reviews show increased risk for CRC in people with a significant family history. Little or no data are available regarding outcome improvements or head-to-head comparisons of the effects of different screening methods. Recommendations for screening rest largely on inference and consensus opinions.
Family history=higher risk at lower age
The US Preventive Services Task Force (USPSTF) recommends CRC screening starting at 50 years of age for patients with average risk, based on a 5.6% lifetime risk of developing CRC and good evidence that screening reduces morbidity and mortality.1 Patients with a family history of CRC or AP have a risk of CRC at 40 years of age that approximates average risk at 50 years.2 Right-sided colonic lesions are also more likely in patients with a family history of CRC (relative risk [RR]=2.25; 95% confidence interval [CI], 1.96-2.59).3
Risk increases with number of affected first-degree relatives
Moreover, systematic reviews show the RR of CRC to be 1.99 (95% CI, 1.55-2.55) in patients with a single first-degree relative with AP, 2.25 (95% CI, 2.00-2.53) with a single first-degree relative with CRC, and 4.25 (95% CI, 3.01-6.02) with 2 or more first-degree relatives with CRC.3
Younger age at diagnosis also increases risk
The effect of the relative’s age at diagnosis of CRC is demonstrated by an RR of 3.87 (95% CI, 2.40-6.22) if diagnosed at younger than 45 years, 2.25 (95% CI, 1.85-2.72) if diagnosed at 45 to 59 years, and 1.82 (95% CI, 1.47-2.25) if diagnosed at 60 years or older.3
Recommendations
Colonoscopy is the preferred screening option for most patients with family histories that put them at increased risk of CRC and right-sided colonic lesions.4,5 The American Cancer Society (ACS) and the American Gastroenterological Association (AGA) recommend that patients with a first-degree relative diagnosed before the age of 60 years or 2 or more first-degree relatives with CRC are at highest risk and should undergo colonoscopy at age 40, or 10 years before the earliest relative’s age at diagnosis; colonoscopy should be repeated every 5 years.4,5
Patients with a first-degree relative diagnosed with CRC or AP at 60 years or older or multiple second-degree relatives with CRC have an increased risk, but lower than the high-risk group.4 Such patients may start screening early, at 40 years, but using the same options as patients at average risk (see the Evidence-Based Answer).4 The TABLE summarizes these screening recommendations. Notably, the ACS recommends no screening change (from patients with average risk) for patients with CRC in second-degree relatives because of the modest increase in risk.5
TABLE
ACS and AGA guidelines for screening patients with a family history of colorectal cancer
| Risk factor | Screening method | Age to start | Surveillance |
|---|---|---|---|
| CRC or AP in 1 first-degree relative diagnosed at <60 yr or multiple first-degree relatives | Colonoscopy | 40 yr, or 10 yr before earliest age at diagnosis of an affected relative | Repeat every 5 years |
| 1 first-degree relative with CRC diagnosed at ≥60 yr or ≥2 second-degree relatives with CRC | Same as average-risk screening* | 40 yr | Same as average-risk screening |
| 1 second-degree or any more distant relatives with CRC | Same as average-risk screening | Same as average-risk screening | Same as average-risk screening |
| *The ACS recommends screening these patients as average risk, meaning that screening should occur at age 50 and can use other recommended screening methods besides colonoscopy. | |||
| ACS, American Cancer Society; AGA, American Gastroenterological Association; AP, adenomatous polyps; CRC, colorectal cancer. | |||
| Adapted from: Winawer S et al. Gastroenterology. 2003 and Smith RA et al. CA Cancer J Clin. 2003.5 | |||
The American Society for Gastrointestinal Endoscopy (ASGE) recommends screening colonoscopy for patients with a first-degree relative who was older than 60 when diagnosed with adenomas but notes that the timing of initial colonoscopy hasn’t been established and should be individualized. The interval for follow-up colonoscopy in these patients should be the same as for average-risk patients. Patients with a second- or third-degree relative with colonic neoplasia should adhere to average-risk screening recommendations.6 Otherwise, the ASGE recommendations agree with the ones described previously.
The most recent joint guidelines of the US Multisociety Task Force (USMSTF) on Colorectal Cancer, the American College of Radiology, and the ACS, released in 2008, make no recommendations regarding patients with a family history.7 The USMSTF defers to guidelines from the ACS and the AGA described earlier.
Acknowledgements
The opinions and assertions contained herein are the private views of the authors and not to be construed as official, or as reflecting the views of the US Air Force Medical Service or the US Air Force at large.
THE BEST APPROACH HINGES on the number, degree, and age of relatives diagnosed with colorectal cancer (CRC) or adenomatous polyps (AP). Screening should begin at 40 years of age for patients with a family history of CRC or AP in at least 1 first-degree relative or CRC in at least 2 second-degree relatives (strength of recommendation [SOR]: B, extrapolation from systematic reviews).
Patients at highest risk—who have 1 first-degree relative diagnosed with CRC or AP before 60 years of age or multiple first-degree relatives diagnosed at any age—should begin screening with colonoscopy at 40 years of age or 10 years younger than the earliest affected relative and undergo a repeat colonoscopy every 5 years (SOR: C, consensus guidelines).
Patients who have a first-degree relative diagnosed with CRC or AP after 60 years of age or 2 or more second-degree relatives with CRC should start screening at 40 years of age, with routine options and follow-up intervals (SOR: C, consensus guidelines). (Routine options and follow-up intervals include any of the following 3 regimens: annual high-sensitivity fecal occult blood testing, sigmoidoscopy every 5 years combined with high-sensitivity fecal occult blood testing every 3 years, or screening colonoscopy every 10 years.1)
Evidence summary
Prospective studies and systematic reviews show increased risk for CRC in people with a significant family history. Little or no data are available regarding outcome improvements or head-to-head comparisons of the effects of different screening methods. Recommendations for screening rest largely on inference and consensus opinions.
Family history=higher risk at lower age
The US Preventive Services Task Force (USPSTF) recommends CRC screening starting at 50 years of age for patients with average risk, based on a 5.6% lifetime risk of developing CRC and good evidence that screening reduces morbidity and mortality.1 Patients with a family history of CRC or AP have a risk of CRC at 40 years of age that approximates average risk at 50 years.2 Right-sided colonic lesions are also more likely in patients with a family history of CRC (relative risk [RR]=2.25; 95% confidence interval [CI], 1.96-2.59).3
Risk increases with number of affected first-degree relatives
Moreover, systematic reviews show the RR of CRC to be 1.99 (95% CI, 1.55-2.55) in patients with a single first-degree relative with AP, 2.25 (95% CI, 2.00-2.53) with a single first-degree relative with CRC, and 4.25 (95% CI, 3.01-6.02) with 2 or more first-degree relatives with CRC.3
Younger age at diagnosis also increases risk
The effect of the relative’s age at diagnosis of CRC is demonstrated by an RR of 3.87 (95% CI, 2.40-6.22) if diagnosed at younger than 45 years, 2.25 (95% CI, 1.85-2.72) if diagnosed at 45 to 59 years, and 1.82 (95% CI, 1.47-2.25) if diagnosed at 60 years or older.3
Recommendations
Colonoscopy is the preferred screening option for most patients with family histories that put them at increased risk of CRC and right-sided colonic lesions.4,5 The American Cancer Society (ACS) and the American Gastroenterological Association (AGA) recommend that patients with a first-degree relative diagnosed before the age of 60 years or 2 or more first-degree relatives with CRC are at highest risk and should undergo colonoscopy at age 40, or 10 years before the earliest relative’s age at diagnosis; colonoscopy should be repeated every 5 years.4,5
Patients with a first-degree relative diagnosed with CRC or AP at 60 years or older or multiple second-degree relatives with CRC have an increased risk, but lower than the high-risk group.4 Such patients may start screening early, at 40 years, but using the same options as patients at average risk (see the Evidence-Based Answer).4 The TABLE summarizes these screening recommendations. Notably, the ACS recommends no screening change (from patients with average risk) for patients with CRC in second-degree relatives because of the modest increase in risk.5
TABLE
ACS and AGA guidelines for screening patients with a family history of colorectal cancer
| Risk factor | Screening method | Age to start | Surveillance |
|---|---|---|---|
| CRC or AP in 1 first-degree relative diagnosed at <60 yr or multiple first-degree relatives | Colonoscopy | 40 yr, or 10 yr before earliest age at diagnosis of an affected relative | Repeat every 5 years |
| 1 first-degree relative with CRC diagnosed at ≥60 yr or ≥2 second-degree relatives with CRC | Same as average-risk screening* | 40 yr | Same as average-risk screening |
| 1 second-degree or any more distant relatives with CRC | Same as average-risk screening | Same as average-risk screening | Same as average-risk screening |
| *The ACS recommends screening these patients as average risk, meaning that screening should occur at age 50 and can use other recommended screening methods besides colonoscopy. | |||
| ACS, American Cancer Society; AGA, American Gastroenterological Association; AP, adenomatous polyps; CRC, colorectal cancer. | |||
| Adapted from: Winawer S et al. Gastroenterology. 2003 and Smith RA et al. CA Cancer J Clin. 2003.5 | |||
The American Society for Gastrointestinal Endoscopy (ASGE) recommends screening colonoscopy for patients with a first-degree relative who was older than 60 when diagnosed with adenomas but notes that the timing of initial colonoscopy hasn’t been established and should be individualized. The interval for follow-up colonoscopy in these patients should be the same as for average-risk patients. Patients with a second- or third-degree relative with colonic neoplasia should adhere to average-risk screening recommendations.6 Otherwise, the ASGE recommendations agree with the ones described previously.
The most recent joint guidelines of the US Multisociety Task Force (USMSTF) on Colorectal Cancer, the American College of Radiology, and the ACS, released in 2008, make no recommendations regarding patients with a family history.7 The USMSTF defers to guidelines from the ACS and the AGA described earlier.
Acknowledgements
The opinions and assertions contained herein are the private views of the authors and not to be construed as official, or as reflecting the views of the US Air Force Medical Service or the US Air Force at large.
1. US Preventive Services Task Force. Screening for colorectal cancer. Rockville, MD: Agency for Healthcare Research and Quality; July 2002. Available at: www.ahrq.gov/clinic/uspstf/uspscolo.htm. Accessed June 11, 2008.
2. Fuchs CS, Giovannucci EL, Colditz GA, et al. A prospective study of family history and the risk of colorectal cancer. N Engl J Med. 1994;331:1669-1674.
3. Johns LE, Houlston RS. A systematic review and meta-analysis of familial colorectal cancer risk. Am J Gastroenterol. 2001;96:2992-3003.
4. Winawer S, Fletcher R, Rex D, et al. Colorectal cancer screening and surveillance: clinical guidelines and rationale—update based on new evidence. Gastroenterology. 2003;124:544-560.
5. Smith RA, Cokkinides V, Eyre HJ. American Cancer Society. American Cancer Society guidelines for the early detection of cancer, 2003. CA Cancer J Clin. 2003;53:27-43.Available at: http://caonline.amcancersoc.org/cgi/content/full/53/1/27. Accessed June 11, 2008.
6. Davila RE, Rajan E, Baron TH, et al. ASGE guideline: colorectal cancer screening and surveillance. Gastrointest Endosc. 2006;63:546-557.
7. Levin B, Lieberman DA, McFarland B, et al. Screening and surveillance for the early detection of colorectal cancer and adenomatous polyps, 2008: a joint guideline from the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology. CA Cancer J Clin. 2008;58:130-160.Available at: http://caonline.amcancersoc.org/cgi/content/full/58/3/130. Accessed on June 11, 2008.
1. US Preventive Services Task Force. Screening for colorectal cancer. Rockville, MD: Agency for Healthcare Research and Quality; July 2002. Available at: www.ahrq.gov/clinic/uspstf/uspscolo.htm. Accessed June 11, 2008.
2. Fuchs CS, Giovannucci EL, Colditz GA, et al. A prospective study of family history and the risk of colorectal cancer. N Engl J Med. 1994;331:1669-1674.
3. Johns LE, Houlston RS. A systematic review and meta-analysis of familial colorectal cancer risk. Am J Gastroenterol. 2001;96:2992-3003.
4. Winawer S, Fletcher R, Rex D, et al. Colorectal cancer screening and surveillance: clinical guidelines and rationale—update based on new evidence. Gastroenterology. 2003;124:544-560.
5. Smith RA, Cokkinides V, Eyre HJ. American Cancer Society. American Cancer Society guidelines for the early detection of cancer, 2003. CA Cancer J Clin. 2003;53:27-43.Available at: http://caonline.amcancersoc.org/cgi/content/full/53/1/27. Accessed June 11, 2008.
6. Davila RE, Rajan E, Baron TH, et al. ASGE guideline: colorectal cancer screening and surveillance. Gastrointest Endosc. 2006;63:546-557.
7. Levin B, Lieberman DA, McFarland B, et al. Screening and surveillance for the early detection of colorectal cancer and adenomatous polyps, 2008: a joint guideline from the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology. CA Cancer J Clin. 2008;58:130-160.Available at: http://caonline.amcancersoc.org/cgi/content/full/58/3/130. Accessed on June 11, 2008.
Evidence-based answers from the Family Physicians Inquiries Network
Which strategies work best to prevent obesity in adults?
A/PHYSICAL ACTIVITY AND DIETARY MODIFICATION WORK BEST. Family involvement, regular weight monitoring, and behavior modification also can help.
Regular physical activity decreases long-term weight gain (strength of recommendation [SOR]: B, 2 high-quality, randomized controlled trials [RCTs]). Decreasing fat intake (SOR: B, 1 high-quality systematic review) and increasing fruit and vegetable consumption (SOR: B, 1 high-quality RCT) also may decrease weight gain. Combined dietary and physical activity interventions prevent weight gain (SOR: B, 1 high-quality systematic review).
Family involvement helps maintain weight (SOR:B, 2 small RCTs). Daily or weekly weight monitoring reduces long-term weight gain (SOR:B, 2 RCTs).
Clinic-based, direct-contact, and Web-based programs that include behavior modification may reduce weight gain in adults (SOR: C, 3 RCTs). Behavior modification delivered by personal contact is more effective than mail, Internet, or self-directed modification programs (SOR:B, 2 RCTs).
Evidence summary
A recent systematic review of obesity prevention studies found 9 RCTs demonstrating that dietary and physical activity interventions can prevent weight gain, but lacking sufficient evidence to recommend a specific type of program.1
A systematic review of the effects of physical activity on weight reduction and maintenance analyzed 46 studies, including 8 RCTs that investigated interventions to reduce weight and 3 that examined measures to maintain it.2 More than 80% of the studies showed a benefit from physical exercise. Prevention of weight gain appears to be dose-dependent. More exercise leads to less weight gain; a minimum of 1.5 hours per week of moderate exercise is needed to prevent weight gain.2
Less fat, more vegetables spur weight loss
The Women’s Health Initiative studied 46,808 postmenopausal women between 50 and 79 years of age who were randomly assigned to an intervention or control group.3 The intervention group received intensive group and individual counseling from dieticians aimed at reducing fat intake to 20%, increasing consumption of vegetables and fruits to 5 or more servings per day, and increasing consumption of grains to 6 or more servings per day. The control group received dietary education materials. Neither group had weight loss or calorie restriction goals or differences in physical activity.
The intervention group had a mean decrease in weight 1.9 kg greater than the controls at 1 year (P<.001) and 0.4 kg at 7.5 years (P<.01). Weight loss was greater in women who consumed more fruits and vegetables and greatest among women who decreased energy intake from fat.
A family-based intervention lowers BMI in females
A family-based trial of weight gain prevention randomized 82 families to a group that was encouraged to eat 2 servings of cereal a day and increase activity by 2000 steps a day, or to a control group.4 In the intervention group, body mass index (BMI) decreased by 0.4% in mothers (P=.027), and BMI percentage for age decreased by 2.6% in daughters (P<.01). Male family members showed no significant differences, however.
Family ties, self-weighing improve weight control
A systematic review of family-spouse involvement in weight control and weight loss found that involving spouses tended to improve the effectiveness of weight control.5
Two studies, 1 an RCT, found an association between self-weighing and preventing weight gain.6,7 Patients who weighed themselves daily or weekly were less likely to gain weight than patients who weighed themselves monthly, yearly, or never.
Getting personal helps modify behavior
Three RCTs compared clinic-based, Web-based, and self-directed advice and counseling to prevent weight gain (2 studies) and maintain weight loss (1 study). In the first study, 67 patients were assigned to 4 months of clinic-based or home-based counseling to increase exercise and reduce fat intake, or to a control group.8 Weight change was–1.9 kg in the clinic-based group,–1.3 kg in the home-based group, and +0.22 kg in the control group (P=.007).
In the second study, 1032 overweight or obese adults with hypertension and/or dyslipidemia who completed a weight-loss program were randomly assigned to receive monthly personal contact, unlimited access to a Web-based intervention, or a self-directed control group.9 At 30 months, participants in the personal contact group had regained less weight than the Web-based or control groups (4.0, 5.1, and 5.5 kg, respectively; P<.01).
A third RCT randomized 284 healthy 25- to 44-year-old women with BMI <30 kg/m2 to group meetings, lessons by mail, or a control group that received an information booklet. The study found no significant difference among the 3 groups in weight maintenance at a 3-year follow-up; 40% maintained weight, and 60% gained more than 2 pounds.10
Recommendations
Wide consensus supports screening by either BMI or height and weight. The US Preventive Services Task Force (USPSTF) recommends intensive counseling for everyone with a BMI ≥30 kg/m2 coupled with behavioral modification to promote sustained weight loss.11 The USPSTF found insufficient evidence to support less intensive counseling for obese patients or counseling of any intensity for overweight patients.
The Canadian Task Force on Preventive Health Care found insufficient evidence to recommend for or against BMI measurement during routine health evaluations of the general population.12
The American Diabetes Association13 and the American College of Preventive Medicine14 recommend counseling and behavior modification for all adults to prevent obesity.
1. Lemmens VE, Oenema A, Klepp KI, et al. A systematic review of the evidence regarding efficacy of obesity prevention interventions among adults. Obes Rev. 2008;9:446-455.
2. Fogelholm M, Kukkonen-Harjula K. Does physical activity prevent weight gain—a systematic review. Obes Rev. 2000;1:95-111.
3. Howard BV, Manson JE, Stefanick ML, et al. Low-fat dietary pattern and weight change over 7 years: the Women’s Health Initiative Dietary Modification Trial. JAMA. 2006;295:39-49.
4. Rodearmel SJ, Wyatt HR, Barry MJ, et al. A family-based approach to preventing excessive weight gain. Obesity (Silver Spring). 2006;14:1392-1401.
5. McLean N, Griffin S, Toney K, et al. Family involvement in weight control, weight maintenance and weight-loss interventions: a systematic review of randomised trials. Int J Obes Relat Metab Disord. 2003;27:987-1005.
6. Linde JA, Jeffery RW, French SA, et al. Self-weighing in weight gain prevention and weight loss trials. Ann Behav Med. 2005;30:210-216.
7. Levitsky DA, Garay J, Nausbaum M, et al. Monitoring weight daily blocks the freshman weight gain: a model for combating the epidemic of obesity. Int J Obes (London). 2006;30:1003-1010.
8. Leermarkers EA, Jakicic JM, Viteri J, et al. Clinic-based vs. home-based interventions for preventing weight gain in men. Obes Res. 1998;6:346-352.
9. Svetkey LP, Stevens VJ, Brantley PJ, et al. Comparison of strategies for sustaining weight loss: the weight loss maintenance randomized controlled trial. JAMA. 2008;299:1139-1148.
10. Levine MD, Klem ML, Kalarchian MA, et al. Weight gain prevention among women. Obesity (Silver Spring). 2007;15:1267-1277.
11. US Preventive Services Task Force. Screening for Obesity in Adults. Rockville, Md: AHRQ; December 2003. Available at: www.ahrq.gov/clinic/uspstf/uspsobes.htm. Accessed May 6, 2008.
12. Douketis JD, Feightner JW, Attia J, et al. Periodic health examination, 1999 update: 1. detection, prevention and treatment of obesity. Canadian Task Force on Preventive Health Care. CMAJ. 1999;160:513-525.
13. Franz MJ, Bantle JP, Beebe CA, et al. Evidence-based nutrition principles and recommendations for the treatment and prevention of diabetes and related complications. Diabetes Care. 2002;25:148-198.
14. Nawaz H, Katz D. American College of Preventive Medicine Medical Practice Policy Statement. Weight management counseling for overweight adults. Am J Prev Med. 2001;21:73-78.
A/PHYSICAL ACTIVITY AND DIETARY MODIFICATION WORK BEST. Family involvement, regular weight monitoring, and behavior modification also can help.
Regular physical activity decreases long-term weight gain (strength of recommendation [SOR]: B, 2 high-quality, randomized controlled trials [RCTs]). Decreasing fat intake (SOR: B, 1 high-quality systematic review) and increasing fruit and vegetable consumption (SOR: B, 1 high-quality RCT) also may decrease weight gain. Combined dietary and physical activity interventions prevent weight gain (SOR: B, 1 high-quality systematic review).
Family involvement helps maintain weight (SOR:B, 2 small RCTs). Daily or weekly weight monitoring reduces long-term weight gain (SOR:B, 2 RCTs).
Clinic-based, direct-contact, and Web-based programs that include behavior modification may reduce weight gain in adults (SOR: C, 3 RCTs). Behavior modification delivered by personal contact is more effective than mail, Internet, or self-directed modification programs (SOR:B, 2 RCTs).
Evidence summary
A recent systematic review of obesity prevention studies found 9 RCTs demonstrating that dietary and physical activity interventions can prevent weight gain, but lacking sufficient evidence to recommend a specific type of program.1
A systematic review of the effects of physical activity on weight reduction and maintenance analyzed 46 studies, including 8 RCTs that investigated interventions to reduce weight and 3 that examined measures to maintain it.2 More than 80% of the studies showed a benefit from physical exercise. Prevention of weight gain appears to be dose-dependent. More exercise leads to less weight gain; a minimum of 1.5 hours per week of moderate exercise is needed to prevent weight gain.2
Less fat, more vegetables spur weight loss
The Women’s Health Initiative studied 46,808 postmenopausal women between 50 and 79 years of age who were randomly assigned to an intervention or control group.3 The intervention group received intensive group and individual counseling from dieticians aimed at reducing fat intake to 20%, increasing consumption of vegetables and fruits to 5 or more servings per day, and increasing consumption of grains to 6 or more servings per day. The control group received dietary education materials. Neither group had weight loss or calorie restriction goals or differences in physical activity.
The intervention group had a mean decrease in weight 1.9 kg greater than the controls at 1 year (P<.001) and 0.4 kg at 7.5 years (P<.01). Weight loss was greater in women who consumed more fruits and vegetables and greatest among women who decreased energy intake from fat.
A family-based intervention lowers BMI in females
A family-based trial of weight gain prevention randomized 82 families to a group that was encouraged to eat 2 servings of cereal a day and increase activity by 2000 steps a day, or to a control group.4 In the intervention group, body mass index (BMI) decreased by 0.4% in mothers (P=.027), and BMI percentage for age decreased by 2.6% in daughters (P<.01). Male family members showed no significant differences, however.
Family ties, self-weighing improve weight control
A systematic review of family-spouse involvement in weight control and weight loss found that involving spouses tended to improve the effectiveness of weight control.5
Two studies, 1 an RCT, found an association between self-weighing and preventing weight gain.6,7 Patients who weighed themselves daily or weekly were less likely to gain weight than patients who weighed themselves monthly, yearly, or never.
Getting personal helps modify behavior
Three RCTs compared clinic-based, Web-based, and self-directed advice and counseling to prevent weight gain (2 studies) and maintain weight loss (1 study). In the first study, 67 patients were assigned to 4 months of clinic-based or home-based counseling to increase exercise and reduce fat intake, or to a control group.8 Weight change was–1.9 kg in the clinic-based group,–1.3 kg in the home-based group, and +0.22 kg in the control group (P=.007).
In the second study, 1032 overweight or obese adults with hypertension and/or dyslipidemia who completed a weight-loss program were randomly assigned to receive monthly personal contact, unlimited access to a Web-based intervention, or a self-directed control group.9 At 30 months, participants in the personal contact group had regained less weight than the Web-based or control groups (4.0, 5.1, and 5.5 kg, respectively; P<.01).
A third RCT randomized 284 healthy 25- to 44-year-old women with BMI <30 kg/m2 to group meetings, lessons by mail, or a control group that received an information booklet. The study found no significant difference among the 3 groups in weight maintenance at a 3-year follow-up; 40% maintained weight, and 60% gained more than 2 pounds.10
Recommendations
Wide consensus supports screening by either BMI or height and weight. The US Preventive Services Task Force (USPSTF) recommends intensive counseling for everyone with a BMI ≥30 kg/m2 coupled with behavioral modification to promote sustained weight loss.11 The USPSTF found insufficient evidence to support less intensive counseling for obese patients or counseling of any intensity for overweight patients.
The Canadian Task Force on Preventive Health Care found insufficient evidence to recommend for or against BMI measurement during routine health evaluations of the general population.12
The American Diabetes Association13 and the American College of Preventive Medicine14 recommend counseling and behavior modification for all adults to prevent obesity.
A/PHYSICAL ACTIVITY AND DIETARY MODIFICATION WORK BEST. Family involvement, regular weight monitoring, and behavior modification also can help.
Regular physical activity decreases long-term weight gain (strength of recommendation [SOR]: B, 2 high-quality, randomized controlled trials [RCTs]). Decreasing fat intake (SOR: B, 1 high-quality systematic review) and increasing fruit and vegetable consumption (SOR: B, 1 high-quality RCT) also may decrease weight gain. Combined dietary and physical activity interventions prevent weight gain (SOR: B, 1 high-quality systematic review).
Family involvement helps maintain weight (SOR:B, 2 small RCTs). Daily or weekly weight monitoring reduces long-term weight gain (SOR:B, 2 RCTs).
Clinic-based, direct-contact, and Web-based programs that include behavior modification may reduce weight gain in adults (SOR: C, 3 RCTs). Behavior modification delivered by personal contact is more effective than mail, Internet, or self-directed modification programs (SOR:B, 2 RCTs).
Evidence summary
A recent systematic review of obesity prevention studies found 9 RCTs demonstrating that dietary and physical activity interventions can prevent weight gain, but lacking sufficient evidence to recommend a specific type of program.1
A systematic review of the effects of physical activity on weight reduction and maintenance analyzed 46 studies, including 8 RCTs that investigated interventions to reduce weight and 3 that examined measures to maintain it.2 More than 80% of the studies showed a benefit from physical exercise. Prevention of weight gain appears to be dose-dependent. More exercise leads to less weight gain; a minimum of 1.5 hours per week of moderate exercise is needed to prevent weight gain.2
Less fat, more vegetables spur weight loss
The Women’s Health Initiative studied 46,808 postmenopausal women between 50 and 79 years of age who were randomly assigned to an intervention or control group.3 The intervention group received intensive group and individual counseling from dieticians aimed at reducing fat intake to 20%, increasing consumption of vegetables and fruits to 5 or more servings per day, and increasing consumption of grains to 6 or more servings per day. The control group received dietary education materials. Neither group had weight loss or calorie restriction goals or differences in physical activity.
The intervention group had a mean decrease in weight 1.9 kg greater than the controls at 1 year (P<.001) and 0.4 kg at 7.5 years (P<.01). Weight loss was greater in women who consumed more fruits and vegetables and greatest among women who decreased energy intake from fat.
A family-based intervention lowers BMI in females
A family-based trial of weight gain prevention randomized 82 families to a group that was encouraged to eat 2 servings of cereal a day and increase activity by 2000 steps a day, or to a control group.4 In the intervention group, body mass index (BMI) decreased by 0.4% in mothers (P=.027), and BMI percentage for age decreased by 2.6% in daughters (P<.01). Male family members showed no significant differences, however.
Family ties, self-weighing improve weight control
A systematic review of family-spouse involvement in weight control and weight loss found that involving spouses tended to improve the effectiveness of weight control.5
Two studies, 1 an RCT, found an association between self-weighing and preventing weight gain.6,7 Patients who weighed themselves daily or weekly were less likely to gain weight than patients who weighed themselves monthly, yearly, or never.
Getting personal helps modify behavior
Three RCTs compared clinic-based, Web-based, and self-directed advice and counseling to prevent weight gain (2 studies) and maintain weight loss (1 study). In the first study, 67 patients were assigned to 4 months of clinic-based or home-based counseling to increase exercise and reduce fat intake, or to a control group.8 Weight change was–1.9 kg in the clinic-based group,–1.3 kg in the home-based group, and +0.22 kg in the control group (P=.007).
In the second study, 1032 overweight or obese adults with hypertension and/or dyslipidemia who completed a weight-loss program were randomly assigned to receive monthly personal contact, unlimited access to a Web-based intervention, or a self-directed control group.9 At 30 months, participants in the personal contact group had regained less weight than the Web-based or control groups (4.0, 5.1, and 5.5 kg, respectively; P<.01).
A third RCT randomized 284 healthy 25- to 44-year-old women with BMI <30 kg/m2 to group meetings, lessons by mail, or a control group that received an information booklet. The study found no significant difference among the 3 groups in weight maintenance at a 3-year follow-up; 40% maintained weight, and 60% gained more than 2 pounds.10
Recommendations
Wide consensus supports screening by either BMI or height and weight. The US Preventive Services Task Force (USPSTF) recommends intensive counseling for everyone with a BMI ≥30 kg/m2 coupled with behavioral modification to promote sustained weight loss.11 The USPSTF found insufficient evidence to support less intensive counseling for obese patients or counseling of any intensity for overweight patients.
The Canadian Task Force on Preventive Health Care found insufficient evidence to recommend for or against BMI measurement during routine health evaluations of the general population.12
The American Diabetes Association13 and the American College of Preventive Medicine14 recommend counseling and behavior modification for all adults to prevent obesity.
1. Lemmens VE, Oenema A, Klepp KI, et al. A systematic review of the evidence regarding efficacy of obesity prevention interventions among adults. Obes Rev. 2008;9:446-455.
2. Fogelholm M, Kukkonen-Harjula K. Does physical activity prevent weight gain—a systematic review. Obes Rev. 2000;1:95-111.
3. Howard BV, Manson JE, Stefanick ML, et al. Low-fat dietary pattern and weight change over 7 years: the Women’s Health Initiative Dietary Modification Trial. JAMA. 2006;295:39-49.
4. Rodearmel SJ, Wyatt HR, Barry MJ, et al. A family-based approach to preventing excessive weight gain. Obesity (Silver Spring). 2006;14:1392-1401.
5. McLean N, Griffin S, Toney K, et al. Family involvement in weight control, weight maintenance and weight-loss interventions: a systematic review of randomised trials. Int J Obes Relat Metab Disord. 2003;27:987-1005.
6. Linde JA, Jeffery RW, French SA, et al. Self-weighing in weight gain prevention and weight loss trials. Ann Behav Med. 2005;30:210-216.
7. Levitsky DA, Garay J, Nausbaum M, et al. Monitoring weight daily blocks the freshman weight gain: a model for combating the epidemic of obesity. Int J Obes (London). 2006;30:1003-1010.
8. Leermarkers EA, Jakicic JM, Viteri J, et al. Clinic-based vs. home-based interventions for preventing weight gain in men. Obes Res. 1998;6:346-352.
9. Svetkey LP, Stevens VJ, Brantley PJ, et al. Comparison of strategies for sustaining weight loss: the weight loss maintenance randomized controlled trial. JAMA. 2008;299:1139-1148.
10. Levine MD, Klem ML, Kalarchian MA, et al. Weight gain prevention among women. Obesity (Silver Spring). 2007;15:1267-1277.
11. US Preventive Services Task Force. Screening for Obesity in Adults. Rockville, Md: AHRQ; December 2003. Available at: www.ahrq.gov/clinic/uspstf/uspsobes.htm. Accessed May 6, 2008.
12. Douketis JD, Feightner JW, Attia J, et al. Periodic health examination, 1999 update: 1. detection, prevention and treatment of obesity. Canadian Task Force on Preventive Health Care. CMAJ. 1999;160:513-525.
13. Franz MJ, Bantle JP, Beebe CA, et al. Evidence-based nutrition principles and recommendations for the treatment and prevention of diabetes and related complications. Diabetes Care. 2002;25:148-198.
14. Nawaz H, Katz D. American College of Preventive Medicine Medical Practice Policy Statement. Weight management counseling for overweight adults. Am J Prev Med. 2001;21:73-78.
1. Lemmens VE, Oenema A, Klepp KI, et al. A systematic review of the evidence regarding efficacy of obesity prevention interventions among adults. Obes Rev. 2008;9:446-455.
2. Fogelholm M, Kukkonen-Harjula K. Does physical activity prevent weight gain—a systematic review. Obes Rev. 2000;1:95-111.
3. Howard BV, Manson JE, Stefanick ML, et al. Low-fat dietary pattern and weight change over 7 years: the Women’s Health Initiative Dietary Modification Trial. JAMA. 2006;295:39-49.
4. Rodearmel SJ, Wyatt HR, Barry MJ, et al. A family-based approach to preventing excessive weight gain. Obesity (Silver Spring). 2006;14:1392-1401.
5. McLean N, Griffin S, Toney K, et al. Family involvement in weight control, weight maintenance and weight-loss interventions: a systematic review of randomised trials. Int J Obes Relat Metab Disord. 2003;27:987-1005.
6. Linde JA, Jeffery RW, French SA, et al. Self-weighing in weight gain prevention and weight loss trials. Ann Behav Med. 2005;30:210-216.
7. Levitsky DA, Garay J, Nausbaum M, et al. Monitoring weight daily blocks the freshman weight gain: a model for combating the epidemic of obesity. Int J Obes (London). 2006;30:1003-1010.
8. Leermarkers EA, Jakicic JM, Viteri J, et al. Clinic-based vs. home-based interventions for preventing weight gain in men. Obes Res. 1998;6:346-352.
9. Svetkey LP, Stevens VJ, Brantley PJ, et al. Comparison of strategies for sustaining weight loss: the weight loss maintenance randomized controlled trial. JAMA. 2008;299:1139-1148.
10. Levine MD, Klem ML, Kalarchian MA, et al. Weight gain prevention among women. Obesity (Silver Spring). 2007;15:1267-1277.
11. US Preventive Services Task Force. Screening for Obesity in Adults. Rockville, Md: AHRQ; December 2003. Available at: www.ahrq.gov/clinic/uspstf/uspsobes.htm. Accessed May 6, 2008.
12. Douketis JD, Feightner JW, Attia J, et al. Periodic health examination, 1999 update: 1. detection, prevention and treatment of obesity. Canadian Task Force on Preventive Health Care. CMAJ. 1999;160:513-525.
13. Franz MJ, Bantle JP, Beebe CA, et al. Evidence-based nutrition principles and recommendations for the treatment and prevention of diabetes and related complications. Diabetes Care. 2002;25:148-198.
14. Nawaz H, Katz D. American College of Preventive Medicine Medical Practice Policy Statement. Weight management counseling for overweight adults. Am J Prev Med. 2001;21:73-78.
Evidence-based answers from the Family Physicians Inquiries Network