All adults, aged 18 years and older, should be screened for obesity, but behavioral counseling about diet and activity for the purpose of preventing cardiovascular disease should be provided only selectively in the primary care setting, according to two newly updated sets of recommendations from the U.S. Preventive Services Task Force.
In an update to 2003 obesity screening and management recommendations, the USPSTF states that all obese adult patients (those with a body mass index of 30 kg/m2 or greater or with a waist circumference indicating obesity) should be offered or referred for intensive, multicomponent behavioral interventions such as weight-loss counseling. The 2003 version called for interventions for overweight individuals with a BMI of between 25 and 29.9 kg/m2, but the latest data did not provide definitive evidence of benefit in this group, USPSTF chair, Dr. Virginia A. Moyer of Baylor College of Medicine, Houston, reported on behalf of the task force (Ann. Intern. Med. 2012;157 [Epub ahead of print 26 June 2012]).
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When it comes to obesity, new recommendations state that all adults over the age of 18 should be screened.
In a second update, the USPSTF concluded that counseling for the purpose of preventing cardiovascular disease in adults without preexisting CVD, hypertension, hyperlipidemia, or diabetes should be provided only in certain patients at the physician’s discretion, rather than incorporated into the care of all adults in the general population. Among those who are obese, however, the evidence indicates that intensive counseling can be of benefit if at least 12-26 sessions are provided in the first year, the task force found.
The updated recommendations are published online in the June 26 Annals of Internal Medicine.
The USPSTF reviewed the latest evidence with respect to the benefits and harms of screening and nonsurgical weight-loss interventions, including 58 trials that looked at behavioral interventions or behavioral interventions plus treatment with either orlistat or metformin, and are considered grade B, indicating high certainty of moderate net benefit, or moderate certainty that the net benefit is moderate to substantial.
Specifically, the USPSTF found "adequate evidence that intensive, multicomponent behavioral interventions for obese adults can lead to an average weight loss of 4 to 7 kg (8.8 to 15.4 lb)."
The evidence also indicates that for obese patients with elevated plasma glucose levels, behavioral interventions decrease the incidence of diabetes diagnosis by about 50% over 2-3 years. Intermediate health outcomes such as blood pressure, waist circumference, and glucose tolerance were also found to improve with behavioral interventions.
Although pharmacologic interventions were associated with improved weight loss and physiologic outcomes, the task force was unable to recommend their use because of concerns about potential harm, including severe liver disease.
The task force acknowledged that intensive interventions may be impractical within many primary care settings, and called for referral to community-based programs for obese patients as needed.
However, even referral to community-based programs could be problematic in some areas, Dr. Zackary D. Berger of Johns Hopkins University, Baltimore, and a primary care doctor, said in an interview.
Although Dr. Berger, a general internist whose research interests include doctor-patient communication, said he finds both sets of recommendations "quite reasonable," he also noted that in the case of the obesity screening and management recommendations, "intensive, multicomponent behavioral interventions are not available for all practices, so any given clinician should think about what they will do for a given patient who turns out to be obese on screening."
Dr. Mary M. Newman, also of Johns Hopkins University and a primary care internist in private practice in Lutherville, Md., said she, too, has concerns about the accessibility –and affordability – of community-based weight-loss counseling programs.
Most internists already screen their patients for obesity, but that doesn’t mean they are providing the intensive counseling – or even talking about weight – in a way that will make a difference. She agreed that "light counseling, admonitions, and mild scolding" are ineffective, and that intensive counseling is needed.
"The problem in many communities will be finding inexpensive-enough programs, or programs that will take insurance," she said, noting that obesity has not been taken seriously enough as a disease except in cases of severe obesity, in which case bariatric surgery is covered.
For example, insurance companies vary tremendously on how much they will pay for an obese patient who doesn’t have diabetes to go to a nutritionist, she said.
"My hope is that this will be an impetus for insurers, communities, hospitals, and doctor organizations to develop affordable options," she said.