Draft Recommendation Sparks Discussion on Overweight, Obesity 

As with most USPSTF draft (and final) recommendations, AAFP News posted an article that summarized the task force's recommendations and offered a family physician's perspective on the issue. In this case, the article sparked a lengthy conversation with different viewpoints, so I would like to clarify a few points.

• First, this is a draft recommendation. Individuals with opinions about the task force's recommendation have until March 19 to provide feedback directly to the task force using the "Leave a Comment" feature on the USPSTF webpages listed above.
  
• Second, multiple physicians took issue with the cost of the interventions recommended by the task force. It's worth noting, however, that the Task Force does not consider the costs of a preventive service when crafting its recommendations "to maintain a clear focus on the science of clinical effectiveness" and "to avoid any misperception that the Task Force's purpose is to limit health care based on cost." It should also be noted that the Patient Protection and Affordable Care Act mandates that most insurers cover A and B recommendations from the USPSTF without cost-sharing.
  
• Third, the current draft recommendation reaffirms the task force's 2012 recommendation, which the Academy agreed with at the time. The AAFP's Subcommittee on Clinical Preventive Services is reviewing the new draft recommendation. After this review is complete, the subcommittee will provide comments to the USPSTF and consider whether the AAFP should agree with the recommendation.

A family physician who was quoted in the AAFP News story said that in most cases, he does not recommend bariatric surgery or weight control medications for his patients. He was speaking for himself, not on behalf of the AAFP. Many primary care clinicians are not comfortable prescribing anti-obesity medications due to concerns about side effects and uncertainty about the evidence base for their use. The USPSTF reviewed the evidence base for pharmacotherapy and noted that in several studies, pharmacotherapy resulted in improved quality of life, greater weight loss and reduced risk of diabetes. Because of the differences between studies, concerns about reporting and unclear applicability to the primary care setting, however, the USPSTF did not make a recommendation for or against the use of pharmacotherapy as a secondary intervention.

The task force considered surgical interventions and nonsurgical weight loss devices to be outside the scope of the primary care setting.

So, what is the AAFP's stance? The AAFP recognizes the increasing prevalence of obesity in the United States and its association with multiple health problems. In addition to the clinical preventive service recommendation mentioned above, the Academy has endorsed the management guideline developed by the American College of Cardiology, the American Heart Association and the Obesity Society.  

Here are some of the key recommendations in that document:

• Overweight is diagnosed by a body mass index (BMI) of 25-29.9 kg/m2 and obesity is diagnosed by a BMI of at least 30 kg/m2.
  
• Individuals with overweight and obesity should be advised that the greater their BMI, the greater the risk of cardiovascular disease, type 2 diabetes and all-cause mortality.
  
• Adults with overweight and obesity and additional cardiovascular risk factors should be counseled that lifestyle changes that produce even modest sustained weight loss of 3 percent to 5 percent produce clinically meaningful health benefits, and that greater weight loss produces greater benefits.
  
• Adults with overweight and obesity should be prescribed a diet to achieve reduced calorie intake.
  
• Individuals with overweight and obesity who would benefit from weight loss should be advised to participate for at least six months in a comprehensive lifestyle program that assists participants in adhering to a lower-calorie diet and in increasing physical activity through behavioral strategies.
  
• Individuals with overweight and obesity who have lost weight should be advised to participate long-term in a comprehensive weight loss maintenance program.
  
• Adults with a BMI of at least 40 kg/m2 or BMI of at least 35 kg/m2 with obesity-related comorbid conditions who are motivated to lose weight, but who have not had a sufficient response to behavioral treatment with or without pharmacotherapy, should be informed about bariatric surgery and offered a referral to an experienced bariatric surgeon for consultation and evaluation.

Like the USPSTF recommendation, this guideline focuses on behavioral counseling and lifestyle interventions. Although the comprehensive evidence base for pharmacotherapy was not included in the review for this guideline, it suggests that, "If the patient has been unable to lose weight or sustain weight loss with comprehensive lifestyle intervention and they have a BMI equal to or greater than 30, or equal to or greater than 27 with comorbidity, adjunctive therapies may be considered."

There is no question that treating obesity is a challenge. The AAFP will continue to review evidence as it emerges to assist our members in optimally treating their patients.

Jennifer Frost, M.D., is medical director of the AAFP's Health of the Public and Science Division.