U.S. Panel: Screen All Adults for Obesity

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]).

© Sean Locke/iStockphoto.com

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.

In general, however, she considers the recommendations to be important and of value, particularly given the rise in obesity, the fact that many obese patients are unaware that they are obese, and the fact that obesity not only is associated with increased mortality, but also is associated with increased disability and decreased quality of life.

The USPSTF reports that since the late 1970s, the prevalence of obesity and overweight in the U.S. have increased by 134% and 48%, respectively, with the prevalence of obesity now exceeding 30% in most age-and sex-specific groups, and with about 1 in 20 Americans having a BMI greater than 40 kg/m².

As for the recommendations on behavioral counseling to promote a healthful diet and physical activity in adults without preexisting cardiovascular disease, the USPSTF update states that in determining which patients should be counseled, clinicians should consider risk factors for cardiovascular disease, a patient’s readiness for change, social support and community resources that help create change, and other health care and preventive service priorities.

These recommendations are based on grade C evidence, indicating moderate certainty that the interventions produce a small net benefit, and are based on the findings of 25 healthful diet counseling trials, 30 physical activity counseling trials, and 17 combined lifestyle counseling trials.

"Although the correlation among healthful diet, physical activity and the incidence of CVD is strong, existing evidence indicates that the health benefit of initiating behavioral counseling in the primary care setting to promote a healthful diet and physical activity is small," Dr. Moyer reported in a separate article on behalf of the USPSTF (Ann. Intern. Med. 2012;157. [Epub ahead of print 26 June 2012]).

Specifically, the evidence that medium- to high-intensity counseling interventions directly decrease rates of mortality or CVD events is inadequate, the task force noted.

In cases when CVD risk is uncertain, the USPSTF recommends using calculators and models, such as the Framingham-based Adult Treatment Panel III calculation.

"Persons with a 10-year risk for CVD greater than 20% are generally considered to be at high risk, those with a 10-year risk less than 10% are considered to be at low risk, and those in the 10% to 20% range are considered to be at intermediate risk. Persons at higher risk may benefit from counseling intervention more than persons at low risk, because even small improvements in intermediate outcomes in those at higher risk may result in clinically meaningful reduction in CVD events," according to the task force.

The strongest evidence for improvement of physiologic outcomes was for high-intensity counseling interventions that were not provided by the primary care clinician in any of the studies that were reviewed.

"Rather, counseling interventions took place in other sectors of the health care system or community settings," they wrote.

Thus, while medium- or high-intensity behavioral interventions to promote a healthful diet and physical activity may be provided to select individual patients in the primary care setting, strong links between the primary care setting and community-based resources may improve delivery of services, they said. Future studies should examine the combined effects of clinical and community-based interventions and the association between small physiologic changes and long-term health outcomes.

"Consistent measurement and reporting of behavioral and risk factor outcomes would also improve the evidence base for behavioral counseling recommendations," they wrote.

Disclosures from individual USPSTF members were not available at press time.

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]).

© Sean Locke/iStockphoto.com

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.

In general, however, she considers the recommendations to be important and of value, particularly given the rise in obesity, the fact that many obese patients are unaware that they are obese, and the fact that obesity not only is associated with increased mortality, but also is associated with increased disability and decreased quality of life.

The USPSTF reports that since the late 1970s, the prevalence of obesity and overweight in the U.S. have increased by 134% and 48%, respectively, with the prevalence of obesity now exceeding 30% in most age-and sex-specific groups, and with about 1 in 20 Americans having a BMI greater than 40 kg/m².

As for the recommendations on behavioral counseling to promote a healthful diet and physical activity in adults without preexisting cardiovascular disease, the USPSTF update states that in determining which patients should be counseled, clinicians should consider risk factors for cardiovascular disease, a patient’s readiness for change, social support and community resources that help create change, and other health care and preventive service priorities.

These recommendations are based on grade C evidence, indicating moderate certainty that the interventions produce a small net benefit, and are based on the findings of 25 healthful diet counseling trials, 30 physical activity counseling trials, and 17 combined lifestyle counseling trials.

"Although the correlation among healthful diet, physical activity and the incidence of CVD is strong, existing evidence indicates that the health benefit of initiating behavioral counseling in the primary care setting to promote a healthful diet and physical activity is small," Dr. Moyer reported in a separate article on behalf of the USPSTF (Ann. Intern. Med. 2012;157. [Epub ahead of print 26 June 2012]).

Specifically, the evidence that medium- to high-intensity counseling interventions directly decrease rates of mortality or CVD events is inadequate, the task force noted.

In cases when CVD risk is uncertain, the USPSTF recommends using calculators and models, such as the Framingham-based Adult Treatment Panel III calculation.

"Persons with a 10-year risk for CVD greater than 20% are generally considered to be at high risk, those with a 10-year risk less than 10% are considered to be at low risk, and those in the 10% to 20% range are considered to be at intermediate risk. Persons at higher risk may benefit from counseling intervention more than persons at low risk, because even small improvements in intermediate outcomes in those at higher risk may result in clinically meaningful reduction in CVD events," according to the task force.

The strongest evidence for improvement of physiologic outcomes was for high-intensity counseling interventions that were not provided by the primary care clinician in any of the studies that were reviewed.

"Rather, counseling interventions took place in other sectors of the health care system or community settings," they wrote.

Thus, while medium- or high-intensity behavioral interventions to promote a healthful diet and physical activity may be provided to select individual patients in the primary care setting, strong links between the primary care setting and community-based resources may improve delivery of services, they said. Future studies should examine the combined effects of clinical and community-based interventions and the association between small physiologic changes and long-term health outcomes.

"Consistent measurement and reporting of behavioral and risk factor outcomes would also improve the evidence base for behavioral counseling recommendations," they wrote.

Disclosures from individual USPSTF members were not available at press time.

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]).

© Sean Locke/iStockphoto.com

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.

In general, however, she considers the recommendations to be important and of value, particularly given the rise in obesity, the fact that many obese patients are unaware that they are obese, and the fact that obesity not only is associated with increased mortality, but also is associated with increased disability and decreased quality of life.

The USPSTF reports that since the late 1970s, the prevalence of obesity and overweight in the U.S. have increased by 134% and 48%, respectively, with the prevalence of obesity now exceeding 30% in most age-and sex-specific groups, and with about 1 in 20 Americans having a BMI greater than 40 kg/m².

As for the recommendations on behavioral counseling to promote a healthful diet and physical activity in adults without preexisting cardiovascular disease, the USPSTF update states that in determining which patients should be counseled, clinicians should consider risk factors for cardiovascular disease, a patient’s readiness for change, social support and community resources that help create change, and other health care and preventive service priorities.

These recommendations are based on grade C evidence, indicating moderate certainty that the interventions produce a small net benefit, and are based on the findings of 25 healthful diet counseling trials, 30 physical activity counseling trials, and 17 combined lifestyle counseling trials.

"Although the correlation among healthful diet, physical activity and the incidence of CVD is strong, existing evidence indicates that the health benefit of initiating behavioral counseling in the primary care setting to promote a healthful diet and physical activity is small," Dr. Moyer reported in a separate article on behalf of the USPSTF (Ann. Intern. Med. 2012;157. [Epub ahead of print 26 June 2012]).

Specifically, the evidence that medium- to high-intensity counseling interventions directly decrease rates of mortality or CVD events is inadequate, the task force noted.

In cases when CVD risk is uncertain, the USPSTF recommends using calculators and models, such as the Framingham-based Adult Treatment Panel III calculation.

"Persons with a 10-year risk for CVD greater than 20% are generally considered to be at high risk, those with a 10-year risk less than 10% are considered to be at low risk, and those in the 10% to 20% range are considered to be at intermediate risk. Persons at higher risk may benefit from counseling intervention more than persons at low risk, because even small improvements in intermediate outcomes in those at higher risk may result in clinically meaningful reduction in CVD events," according to the task force.

The strongest evidence for improvement of physiologic outcomes was for high-intensity counseling interventions that were not provided by the primary care clinician in any of the studies that were reviewed.

"Rather, counseling interventions took place in other sectors of the health care system or community settings," they wrote.

Thus, while medium- or high-intensity behavioral interventions to promote a healthful diet and physical activity may be provided to select individual patients in the primary care setting, strong links between the primary care setting and community-based resources may improve delivery of services, they said. Future studies should examine the combined effects of clinical and community-based interventions and the association between small physiologic changes and long-term health outcomes.

"Consistent measurement and reporting of behavioral and risk factor outcomes would also improve the evidence base for behavioral counseling recommendations," they wrote.

Disclosures from individual USPSTF members were not available at press time.