Perspective

USPSTF draft recommendation: Refer, offer patients with obesity to behavioral weight loss interventions

David Grossman
David C. Grossman

The U.S. Preventive Services Task Force has issued a draft recommendation affirming its 2012 final decision that clinicians with adult patients who have a BMI of 30 kg/m2 or more refer or offer intensive, multicomponent behavioral interventions to that patient.

The “B” level recommendation came after a review of 89 weight loss and behavior-based weight loss maintenance trials, according to the draft statement.

“The Task Force reviewed the most recent evidence on whether intensive behavioral interventions with multiple components can lead to weight loss and other benefits for people who have obesity,” David C. Grossman, MD, MPH, task force chair, and adjunct professor of pediatrics and professor of health services at the University of Washington, told Healio Family Medicine. “Based on the research, we found that these interventions —which include a variety of programs that encourage healthy eating and exercise habits —are safe, effective, and can help people with obesity improve their health.”

Though the draft statement indicated programs containing group sessions and combine several activities had the greatest impact on patients losing weight, Grossman said in the interview that determining which treatment would work best is not necessarily one size fits all.

“Primary care physicians should talk to patients who have a BMI of 30 kg/m2 or higher about the different weight loss interventions that are available so they can make the best choice for themselves,” he said. “For example, some patients may prefer one-on-one counseling, while others may find a web- or group-based intervention more helpful. Physicians should use their best judgment and take into account their patients’ preferences and health concerns when deciding whether or not to refer people to counseling.”

The task force also evaluated pharmaceutical approaches in several countries, including the United States, involving phentermine-topiramate, orlistat, naltrexone and bupropion and lorcaserin.

“Participant characteristics were similar to those in the behavioral intervention trials. Many trials required participants to demonstrate medication compliance and/or meet weight loss goals prior to enrollment,” the task force wrote. “The more narrowly defined inclusion criteria of these trials resulted in more selective populations enrolled as study participants Meta-analyses could not be conducted because of the few number of trials for each drug or variability in outcome reporting.”

Grossman outlined where several research gaps still exist in spite of the task force’s “B” recommendation.

“More studies are needed that look at the effect of screening for obesity on long-term weight and health outcomes, especially in groups like older adults, racial and ethnic minorities, and patients with overweight,” he said. “Additionally, it would be helpful to further examine quality of life and patient-centered outcomes of interventions, as well as factors such as genetics and unmanaged psychological conditions that may prevent adults from losing weight during these programs.”

According to the task force, the American Academy of Family Physicians recommends screening for obesity in all adults and referring or offering patients with a BMI of 30 kg/m2 or more to intensive, multicomponent behavioral interventions. In addition, the American College of Endocrinology and American Association of Clinical Endocrinologists recommend screening for obesity with BMI and using waist circumference as a supplement in adults with a BMI of more than 35 kg/m2. The American Heart Association and American College of Cardiology recommend screening for obesity with BMI and waist circumference in adults.

The USPSTF’s draft statement and evidence review has been posted for public comment on the USPSTF website: www.uspreventiveservicestaskforce.org. Input will be accepted through March 19, 2018, at www.uspreventiveservicestaskforce.org/tfcomment.htm. - by Janel Miller

Disclosure: Grossman reports being an investigator at Kaiser Permanente Washington Health Research Institute, which subcontracts with the Kaiser Permanente Research Affiliates Evidence-based Practice Center, which conducts the evidence review for certain topics. He reports no ties to any members of the team performing the evidence reviews.

David Grossman
David C. Grossman

The U.S. Preventive Services Task Force has issued a draft recommendation affirming its 2012 final decision that clinicians with adult patients who have a BMI of 30 kg/m2 or more refer or offer intensive, multicomponent behavioral interventions to that patient.

The “B” level recommendation came after a review of 89 weight loss and behavior-based weight loss maintenance trials, according to the draft statement.

“The Task Force reviewed the most recent evidence on whether intensive behavioral interventions with multiple components can lead to weight loss and other benefits for people who have obesity,” David C. Grossman, MD, MPH, task force chair, and adjunct professor of pediatrics and professor of health services at the University of Washington, told Healio Family Medicine. “Based on the research, we found that these interventions —which include a variety of programs that encourage healthy eating and exercise habits —are safe, effective, and can help people with obesity improve their health.”

Though the draft statement indicated programs containing group sessions and combine several activities had the greatest impact on patients losing weight, Grossman said in the interview that determining which treatment would work best is not necessarily one size fits all.

“Primary care physicians should talk to patients who have a BMI of 30 kg/m2 or higher about the different weight loss interventions that are available so they can make the best choice for themselves,” he said. “For example, some patients may prefer one-on-one counseling, while others may find a web- or group-based intervention more helpful. Physicians should use their best judgment and take into account their patients’ preferences and health concerns when deciding whether or not to refer people to counseling.”

The task force also evaluated pharmaceutical approaches in several countries, including the United States, involving phentermine-topiramate, orlistat, naltrexone and bupropion and lorcaserin.

“Participant characteristics were similar to those in the behavioral intervention trials. Many trials required participants to demonstrate medication compliance and/or meet weight loss goals prior to enrollment,” the task force wrote. “The more narrowly defined inclusion criteria of these trials resulted in more selective populations enrolled as study participants Meta-analyses could not be conducted because of the few number of trials for each drug or variability in outcome reporting.”

Grossman outlined where several research gaps still exist in spite of the task force’s “B” recommendation.

“More studies are needed that look at the effect of screening for obesity on long-term weight and health outcomes, especially in groups like older adults, racial and ethnic minorities, and patients with overweight,” he said. “Additionally, it would be helpful to further examine quality of life and patient-centered outcomes of interventions, as well as factors such as genetics and unmanaged psychological conditions that may prevent adults from losing weight during these programs.”

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According to the task force, the American Academy of Family Physicians recommends screening for obesity in all adults and referring or offering patients with a BMI of 30 kg/m2 or more to intensive, multicomponent behavioral interventions. In addition, the American College of Endocrinology and American Association of Clinical Endocrinologists recommend screening for obesity with BMI and using waist circumference as a supplement in adults with a BMI of more than 35 kg/m2. The American Heart Association and American College of Cardiology recommend screening for obesity with BMI and waist circumference in adults.

The USPSTF’s draft statement and evidence review has been posted for public comment on the USPSTF website: www.uspreventiveservicestaskforce.org. Input will be accepted through March 19, 2018, at www.uspreventiveservicestaskforce.org/tfcomment.htm. - by Janel Miller

Disclosure: Grossman reports being an investigator at Kaiser Permanente Washington Health Research Institute, which subcontracts with the Kaiser Permanente Research Affiliates Evidence-based Practice Center, which conducts the evidence review for certain topics. He reports no ties to any members of the team performing the evidence reviews.

    Perspective
    Adam Tsai

    Adam G. Tsai

    This is the third time the U.S. Preventive Services Task Force has looked at obesity since 2003. However, this is the first time that the USPSTF has included medications in their review. The USPSTF recommendations on high intensity behavioral treatment are similar to past recommendations from 2003 and 2012.

    With regard to pharmacotherapy, the USPSTF raised questions about weight trajectory after pharmacotherapy is stopped.  This is a problematic view of medications to treat obesity, since all the medications approved by the FDA since 2012 are recommended for long term use.  The USPSTF also did not review the use of phentermine, which is by far the most commonly prescribed weight loss medication in the United States. Although this decision is rational in the sense that this agent is not FDA-approved for long-term use, it is also problematic in that the task force is reviewing clinical trials of drugs that are less commonly used and hence, less applicable to practicing clinicians and their patients. The 2015 Endocrine Society guideline on use of medications to treat obesity has explicit discussion of the appropriate off-label use of phentermine for long term use.

    However, there are still messages within the recommendations that are useful for primary care physicians. For example, one new finding in this review was that interventions that included group visits were more effective than interventions that did not include them. Second, this publication from USPSTF reiterates the importance of structured, high-intensity behavioral programs for treatment of obesity. Thus, physicians encountering patients who believe they have already tried all modalities for weight loss should always ask whether the patient has previously participated in a structured, high-intensity program that includes in-person visits.

    • Adam G. Tsai, MD, MSCE
    • Internist and Obesity Medicine physician in Denver, Colorado
      Chair, Education Committee, The Obesity Society

    Disclosures: Tsai reports no relevant financial disclosures.