From the Journals

Task force advises behavioral intervention for obese adults

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Behavioral therapies alone may not be enough

In the USPSTF Recommendation Statement on Behavioral Weight Loss Interventions to Prevent Obesity-Related Morbidity and Mortality in Adults the Task Force updates their 2012 statement and recommends that patients with obesity be referred for intensive, multicomponent behavioral weight loss interventions and weight loss maintenance. Reiterating the importance of intensive behavioral and lifestyle support is to be commended and should be the cornerstone of treatment for people with overweight disorders. As thoughtfully discussed in accompanying editorials by Haire-Joshu, Hill-Briggs, and Yanovski, moving from recommendation to reality will require access to high-quality programs for patients of all socioeconomic and ethnic backgrounds, less restrictive reimbursement for services, and broader involvement of the public health and food industry sectors.

However, the task force recommendations were limited in scope: they pertained to people with obesity defined as a BMI greater than 30 kg/m2, to those without diagnosed obesity-associated disorders, and to patients seen in a primary care setting. This lessens the impact of the report for a disease which continues to be epidemic in the United States. Leaving out the overweight pre-obese in whom efforts toward prevention are essential, as well as people with obesity who have coexisting comorbidities restricts the recommendations to one slice of the large obesity pie. As more high-quality data pertaining to a broader range of people impacted by overweight disorders become available, more expansive guidelines for treatment will be important.

Furthermore, while behavioral weight loss interventions are meaningful, they fall short for many in bringing about sustained efficacy. The primary care setting should include referral for appropriate patients to be evaluated for combined multidisciplinary behavioral and surgical, endoscopic, or pharmacologic therapies that can improve clinical outcomes for those refractory to behavioral weight loss interventions alone. Finally, tackling the obesity epidemic requires that health care providers across a broad range of specialties become involved in a coordinated effort to help our patients. As digestive disease specialists treating a myriad of obesity-related diseases from fatty liver to colorectal cancer, we too need to help address the underlying disease by providing obesity therapy within our practices or making referrals for its multidisciplinary treatment.

Sarah Streett, MD, AGAF, clinical associate professor of medicine, division of gastroenterology and hepatology, Stanford University School of Medicine, Stanford, Calif. She has no relevant disclosures.


 

FROM JAMA

The U.S. Preventive Services Task Force advises clinicians to refer or offer intensive behavioral weight-loss interventions to obese adults, according to an updated recommendation statement published in JAMA.

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Obesity affects more than one-third of U.S. adults, according to federal statistics. It carries increased risk for comorbidities including heart disease, diabetes, and various cancers, as well as increased risk of death among adults younger than 65 years, noted lead author Susan J. Curry, PhD, of the University of Iowa, Iowa City, and members of the Task Force.

The B recommendation applies to obese adults; obesity was defined as a body mass index of 30 kg/m2 or higher. The evidence review focused on interventions for weight loss and weight maintenance that could be provided in primary care or referred from primary care, such as nutrition counseling, exercise strategies, and goal setting.

The Task Force found adequate evidence that behavior-based weight-loss interventions improved weight, reduced incidence of type 2 diabetes, and helped maintain weight loss after interventions ended.

The Task Force found small to no evidence of harm associated with any of the behavioral weight-loss interventions, which included group sessions, personal sessions, print-based interventions, and technology-based interventions (such as text messages). Although interventions that combined drug therapy with behavioral intervention resulted in greater weight loss over 12-18 months, compared with behavioral interventions alone, the attrition rates were high and data on weight-loss maintenance after discontinuation of the drugs were limited, the Task Force noted.

“As a result, the USPSTF encourages clinicians to promote behavioral interventions as the primary focus of effective interventions for weight loss in adults,” they wrote.

The Task Force acknowledged the need for future research in subgroups and to explore whether factors such as genetics and untreated conditions are barriers to behavior-based weight loss interventions.

In the evidence review published in JAMA, Erin S. LeBlanc, MD, of Kaiser Permanente in Portland, Ore., and her colleagues reviewed data from 122 randomized, controlled trials including more than 62,000 persons and 2 observational studies including more than 209,000 persons.

The researchers found behavioral interventions were associated with greater weight loss and less risk of developing diabetes, compared with control interventions.

Intensive behavioral interventions included counseling patients about healthy eating, encouraging physical activity, setting weight and health goals, and assisting with weight monitoring. The interventions ranged from text messaging to in-person sessions for individuals or groups. The average absolute weight loss in the trials included in the review ranged from –0.5 kg to –9.3 kg (–1.1 lb to –20.5 lb) for intervention patients and from +1.4 kg to –5.6 kg (+3.1 lb to –12.3 lb) in controls.

Limitations of the review included a lack of data on population subgroups and a lack of long-term data on weight and health outcomes, the researchers noted. However, the results support the value of behavior-based therapy for obesity treatment.

The final recommendation is consistent with the 2018 draft recommendation and updates the 2012 final recommendation on obesity management.

The researchers and Task Force members had no relevant financial conflicts to disclose.

SOURCE: U.S. Preventive Services Task Force. JAMA. 2018;320(11):1163-71. doi: 10.1001/jama.2018.13022.

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