USPSTF Recommendations on Obesity

HealthCare

From: http://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/obesity-in-adults-screening-and-management?ds=1&s=Obesity

Obesity in Adults, Screening for and Management of, 2012

Clinical Considerations:

Patient Population Under Consideration

 

      This recommendation applies to adults aged 18 years or older. The USPSTF uses the following terms to define categories of increased BMI: overweight is defined as a BMI of 25 to 29.9 kg/m2, and obesity is defined as a BMI of 30 kg/m2or higher.

 

Interventions

 

      The USPSTF found that the most effective interventions were comprehensive and were of high intensity (12 to 26 sessions in a year). Although the USPSTF could not determine the effectiveness of other specific intervention components, most of the higher-intensity behavioral interventions included multiple behavioral management activities, such as group sessions, individual sessions, setting weight-loss goals, improving diet or nutrition, physical activity sessions, addressing barriers to change, active use of self-monitoring, and strategizing how to maintain lifestyle changes.Weight-loss outcomes improved when interventions involved more sessions (12 to 26 sessions in the first year). Behavioral intervention participants lost an average of 6% of their baseline weight (4 to 7 kg [8.8 to 15.4 lb]) in the first year with 12 to 26 treatment sessions compared with little or no weight loss in the control group participants. A weight loss of 5% is considered clinically important by the U.S. Food and Drug Administration (FDA).For obese patients with elevated plasma glucose levels, behavioral interventions decreased the incidence of diabetes diagnosis by about 50% over 2 to 3 years (number needed to treat, 7). Behavioral interventions also demonstrated some improvement in intermediate health outcomes, such as blood pressure, waist circumference, and glucose tolerance.Interventions that combine pharmacologic agents (orlistat or metformin) with behavioral interventions resulted in weight loss and improvement in physiologic outcomes. Orlistat led to an average weight loss of about 2.6 kg (5.7 lb), a 1.9-cm decrease in waist circumference, and a decrease in fasting glucose level. However, there are concerns about the potential harms of orlistat because of recent FDA reports of rare severe liver disease and a lack of long-term safety data. Metformin led to a 1.5-cm greater decrease in waist circumference; however, its use for obesity is not approved by the FDA and is thus considered an off-label use. In addition, sufficient data were lacking about the maintenance of improvement after discontinuation of medications. As a result, the USPSTF is unable to recommend medication use.Results of trials were not stratified by BMI category, making it difficult to ascertain the certainty of benefit in overweight (BMI of 25 to 29.9 kg/m2) groups. Although some studies included overweight participants, the mean BMI across trials was in the obese range (≥30 kg/m2). Therefore, the USPSTF was unable to examine differential effects of interventions on both overweight and obese patients. However, the recommended interventions may also lead to weight loss in some overweight patients. Compared with that of obesity, less is known about the association of overweight and long-term health outcomes.

 

Screening Intervals

 

      No evidence was found regarding appropriate intervals for screening.

Other Considerations

 

Implementation

 

      Although intensive interventions may be impractical within many primary care settings, patients may be referred from primary care to community-based programs for these interventions.

 

Research Needs and Gaps

 

      Further research is needed to examine the direct effects of screening for obesity on long-term weight and health outcomes. More specific areas for further research include determining if weight-loss interventions lead to long-term weight loss and improvements in health outcomes. Studies are needed that reassess the best methods for screening in adults (for example, waist circumference or waist–hip ratio), address weight management in elderly adults and other subpopulations, and examine the cost-effectiveness of behavioral and pharmacologic interventions. Comparative effectiveness trials could provide more evidence about the components of an effective intervention.

 

Response to Public Comments

 

      A draft of this recommendation statement was posted for public comment on the USPSTF Web site from 26 October to 23 November 2011. All comments received were reviewed during the creation of the final recommendation statement. Specifically, responses to these comments led to clarification of the definition of “intensive” and “multicomponent” in the Clinical Considerations and Discussion sections. The Implementation section was expanded to reflect referral to community-based programs. The Recommendations of Others section was expanded to include recommendations from other professional associations. The Clinical Considerations section was expanded to clarify why overweight was not included in the recommendation statement. The Scope of the Review section was refined to clarify the scope of the update. Some respondents asked about costs. The USPSTF does not consider costs in its appraisal of the effectiveness of a service.

Update of Previous USPSTF Recommendation

 

      In 2003, the USPSTF recommended that clinicians screen all adult patients for obesity and offer intensive counseling and behavioral interventions to promote sustained weight loss in obese adults (

B recommendation

      ). The USPSTF concluded that the evidence was insufficient to recommend for or against the use of moderate- or low-intensity counseling together with behavioral interventions to promote sustained weight loss in obese adults (

I statement

      ) or the use of counseling of any intensity with behavioral interventions to promote sustained weight loss in overweight adults (

I statement

    ). One change in the current recommendation is that the USPSTF found adequate evidence that intensive, multicomponent behavioral interventions for obese adults can also improve glucose tolerance and other physiologic risk factors for cardiovascular disease. Another change in the current recommendation is that it addresses only individuals with a BMI of 30 kg/m2 or higher; it does not address the effectiveness of screening in overweight adults with a BMI of 25 to 29.9 kg/m2. Although some studies included overweight patients, the differential effects of the interventions on overweight versus obesity could not be determined.

Rationale:

Importance

 

The prevalence of obesity in the United States is high, exceeding 30% in adult men and women. Obesity is associated with such health problems as an increased risk for coronary heart disease, type 2 diabetes mellitus, various types of cancer, gallstones, and disability. These comorbid medical conditions are associated with higher use of health care services and costs among obese patients.Obesity is also associated with an increased risk for death, particularly in adults younger than 65 years. The leading causes of death in obese adults include ischemic heart disease, diabetes, respiratory diseases, and cancer (for example, liver, kidney, breast, endometrial, prostate, and colon). Weight loss in obese individuals is associated with a lower incidence of health problems and death.

 

Detection

 

Body mass index is calculated from the measured weight and height of an individual. Recent evidence suggests that waist circumference may be an acceptable alternative to BMI measurement in some patient subpopulations. Screening tests were not a specific focus of this review.

 

Benefits of Detection and Early Intervention/Treatment

 

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). These interventions also improve glucose tolerance and other physiologic risk factors for cardiovascular disease.The USPSTF found inadequate direct evidence about the effectiveness of these interventions on long-term health outcomes (for example, death, cardiovascular disease, and hospitalizations).

 

Harms of Detection and Early Intervention/Treatment

 

Adequate evidence indicates that the harms of screening and providing behavioral interventions for obesity are no greater than small.

 

USPSTF Assessment

 

The USPSTF concludes with moderate certainty that screening for obesity in adults has a moderate net benefit. There is also benefit to offering or referring obese adults to intensive behavioral interventions to improve weight status and other risk factors for important health outcomes.

* Indicates a new grade definition.

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