February 21, 2018, 02:51 pm Chris Crawford – (Editor's Note: Jennifer Frost, M.D., medical director for the AAFP Health of the Public and Science Division, responds to comments generated by this AAFP News story in a guest editorial posted on March 6.)
More than 30 percent of U.S. adults have obesity, a disease that is associated with numerous chronic and life-threatening health issues, including cardiovascular disease, type 2 diabetes and various types of cancer.
However, evidence has shown that intensive behavioral programs that include a variety of activities can help patients with obesity manage their weight.
On Feb. 20, the U.S. Preventive Services Task Force (USPSTF) posted a draft recommendation statement and draft evidence review on behavioral weight loss interventions to prevent obesity-related morbidity and mortality in adults.
Based on its review of the evidence, the USPSTF recommended that clinicians offer or refer adults with a body mass index (BMI) of 30 kg/m2 or higher to intensive, multicomponent behavioral interventions -- a "B" recommendation.
"The task force found that intensive, multicomponent behavioral programs are safe and effective, and they can help patients lose weight and reduce risk factors for heart disease," said USPSTF Chair David Grossman, M.D., M.P.H., in a news release. "There are many programs available, so we encourage people to talk to their clinician about what might work best for them."
The USPSTF said these programs commonly include group sessions (at least 12 sessions or more in the first year) and help patients make healthy eating choices, encourage them to increase physical activity and help them monitor their own weight.
"Of the programs we examined, those that combined multiple activities and included group sessions had the strongest effect," said task force member Chyke Doubeni, M.D., M.P.H., in the release. "Evidence shows that people regain less weight with these types of programs."
This draft recommendation reaffirms the USPSTF's 2012 final recommendation, which the AAFP agreed with in its own recommendation at the time.
The USPSTF commissioned a systematic evidence review to update its 2012 recommendation on screening for obesity in adults, reviewing evidence on interventions for weight loss or weight loss maintenance that can be provided in or referred from a primary care setting.
Surgical weight loss interventions and nonsurgical weight loss devices (e.g., gastric balloons) were considered outside the scope of the primary care setting.
Specifically, the task force reviewed evidence on four types of interventions: behavior-based weight loss (80 trials), behavior-based weight loss maintenance (nine trials), pharmacotherapy-based weight loss (32 trials) and pharmacotherapy-based weight loss maintenance (three trials).
Thirty trials examined the harms of behavior-based weight loss and weight maintenance interventions, and 33 trials and two observational studies assessed the harms of pharmacotherapy-based weight loss and weight maintenance interventions.
Overall, the task force found "adequate evidence that intensive, multicomponent behavioral interventions in adults with obesity can lead to clinically significant improvements in weight status and reduce the incidence of type 2 diabetes among adults with obesity and elevated plasma glucose levels; these interventions are of moderate benefit." Specifically, adequate evidence showed that behavior-based weight loss maintenance interventions are of moderate benefit.
The USPSTF also found adequate evidence that the harms of intensive, multicomponent behavioral interventions in adults with obesity are small to none, leading task force members to conclude with moderate certainty that offering or referring adults with obesity to intensive behavioral interventions or behavior-based weight loss maintenance interventions has a moderate net benefit.
Family physician Robert Sallis, M.D., co-director of the Sports Medicine Fellowship at Kaiser Permanente in Fontana, Calif., told AAFP News he suggests patients with obesity set their sights on making small changes.
"I think it's overwhelming if you tell a patient they need to lose 60 pounds -- it's not going to happen," he said. "Patients should focus on the small successes, such as losing 10 pounds, or just holding their weight constant."
Sallis said patients also need to really focus on eating healthy foods. "In my experience, a high fat/low carb diet often is the most sustainable," he said. "Any diet works; but the key is picking one that patients can sustain."
As to the benefits of group sessions in treating obesity, Sallis said Kaiser Permanente has offered them for a number of years and they seem to be a good jumping-off point.
"The group classes are part of the menu we offer; they will work for some but not others," he said. "Teaching patients what to eat is a great start, but the sessions don't get at the underlying motivations and how we change those behaviors."
Sallis said he also recommends his patients avoid bariatric surgery and weight control medications in most cases.
"Medications for weight loss don't make any logical sense to me," he said. "These patients lose weight in the short run but then they gain it back as soon as they go off the medications. And certainly, over the years, we've seen some horrible complications from diet pills."
As for bariatric surgery, Sallis said he generally recommends against it, except in patients who are morbidly obese with serious complications. "So many patients who have this surgery gain their weight back or have complications," he explained. "In fact, I've had two patients die related to complications from bariatric surgery."
Sallis also stressed the importance of optimizing other lifestyle factors in patients with obesity, such as exercise and smoking cessation.
"Too often these issues get lost in the discussions about weight, and studies suggest regular exercise has a much more powerful effect on health than merely losing weight," he said.
That's why he puts a strong focus on getting an obese patient who's been sedentary to begin exercising. Sallis said he starts by suggesting five to 10 minutes of walking a day to build on, with the goal of 30 minutes a day and beyond as the patient gets into shape. He said it's important to note that the health benefits of exercise are independent of losing weight.
It's also helpful that patients now can also use smartphone apps or other health devices to track their progress with both diet and exercise, according to Sallis. For example, the iPhone has a built-in Health app that tracks activity and nutrition, among other things, he noted.
Sallis also recommended MyFitnessPal, a free app and website that tracks diet and exercise to determine optimal caloric intake and nutrients based on patients' goals.
"It helps patients understand what they're eating, and many are surprised by the number of calories they eat," he said.
Sallis said he's also seen great success with his patients using external fitness trackers such as the Fitbit, which allow them to compete with friends, co-workers or even people across the country using metrics such as the number of steps they take per day.
"Clearly, what we've been doing so far in the United States has not been working," he concluded. "You can see the explosion in obesity that's occurring by looking at the CDC's Adult Obesity Prevalence maps. We need to rethink how we look at this. There is more to health than just your BMI and you cannot diet away the harmful health effects of being sedentary and smoking."
The USPSTF is inviting comments on its draft recommendation statement and draft evidence review on behavioral interventions for adult obesity.
The public comment window for the draft recommendation and draft evidence review is open until 8 p.m. EST on March 19. All comments received will be considered as the task force prepares its final recommendation.
The AAFP will review the USPSTF's draft recommendation statement and supporting evidence and provide comments to the task force. The Academy will release its own recommendation on the topic after the task force finalizes its guidance.