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Clinicians should suggest or refer obese adults (a body mass index [BMI] 30 kg / m2 persons or higher) to intensive multicomponent behavioral interventions, according to a statement of recommendation updated by the US Preventive Services Task Force (USPSTF).
The new directive reaffirms that issued in 2012 and constitutes a "B" recommendation, which means that there is a high certainty of a moderate net profit or a moderate certainty of a profit net moderate to substantial. It is designed for adults with obesity who have not yet developed other diseases associated with obesity, such as diabetes or coronary heart disease.
"We focus on prevention, we try to prevent diabetes and cardiovascular disease, there are groups that make recommendations on how to treat these diseases that we consider out of reach," says Chyke A. Doubeni, MD School of Medicine, University of Pennsylvania, Philadelphia, stated Medscape Medical News.
He pointed out that although these new recommendations focus on people without diseases, they "could still work in people with diseases."
"More than 35% of men and 40% of women in the United States are obese. Obesity is associated with health problems such as increased risk of coronary heart disease, type 2 diabetes, various types of cancer, gallstones and disability. also associated with an increased risk of death, especially among adults under 65, "say the authors of the guidelines, led by the USPSTF President, Susan J. Curry, PhD, of the University of Iowa , Iowa City.
The new recommendation was posted online September 18 JAMA on behalf of the USPSTF. A report on the evidence, an editorial and a patient education page appear in the same issue and follow a draft recommendation published in February.
Pharmacotherapy not recommended for the moment
The new evidence review examined five anti-obesity drugs approved by the US Food and Drug Administration; When the 2012 recommendation was issued, orlistat was the only approved obesity drug for long-term use in the United States.
Patients who combined pharmacotherapy with behavioral interventions reported greater weight loss and maintained better weight loss over 12 to 18 months, compared with patients who used only behavioral interventions.
However, "there were gaps in the evidence for the drugs that prevented us from including them in the recommendations," said Doubeni. Medscape Medical News.
"For each of the drugs … there was a limited number of trials, so … we were not able to share the results, but the most important thing is that we know that". there are inconveniences and these damages have not been very well studied, "he added.
"Participants in pharmacotherapeutic trials were required to meet very selective inclusion criteria, including adherence to drug therapy and achieving weight loss goals prior to recruitment." These trials were also characterized by high attrition, these tests are applicable to the general primary care population in the United States, "explain the authors of the recommendation.
Doubeni insisted that multicomponent behavioral interventions, which include many elements over an extended period of time, such as counseling on a healthy diet, physical exercise, setting goals and self-monitoring, are stronger.
The task force is not as comfortable with the evidence on the drugs, he reiterated.
In his accompanying editorial, titled "Weight Management in Adults with Obesity, What's a Primary Care Clinician Must Do?" Susan Z. Yanovski, MD, of the National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, said, "Additional pragmatic trials in primary care populations would help determine the # 39; s efficiency. [of obesity medications] in a clinical setting. "
"Some patients respond to adjunctive drug therapy with clinically significant weight loss and favorable improvements in comorbidities related to obesity, while others lose little weight, exhibit low levels of body weight, and have low weight. improvements in health problems related to obesity or unacceptable adverse effects ".
"Primary care clinicians are in an ideal position to assess the risks and benefits of adjunct pharmacotherapy in their patients and to monitor the effects of treatment," Yanovski adds.
The review excludes studies with T2D, patients with cardiovascular disease and editorialists
The new recommendations are for adults who do not have any concomitant illness requiring weight loss as part of the management of the disease.
Yanovski believes that the evidence review may be incomplete with respect to behavioral interventions and pharmacotherapy, as it excludes "some long-term clinical trials in patients with type 2 diabetes or cardiovascular disease" .
Although this strategy may improve the specificity of the study results for obesity-related patient populations, it does not take into account the important data on the effect of management interventions of the population. among the many patients treated by clinicians. .
For example, the Action for Health in Diabetes study (AHEAD Look) was a randomized clinical trial comparing the effects of an intensive lifestyle intervention in support of diabetes and education on the health effects of 5145 adults with overweight / obesity diabetes over 10 years.
"Although the intensive lifestyle intervention did not have a beneficial effect on the morbidity and mortality associated with cardiovascular disease, this intervention had beneficial effects on health: sleep apnea, urinary incontinence, preservation of physical mobility, depression and quality of life related to physical health, "says Yanovski.
"With some large, long-term studies of weight management interventions evaluating important health outcomes, these data may also help inform decision-making for the broader population of patients with obesity," adds -t it.
Doubeni said the findings of the AHEAD Look trial were "essentially the same as we found and reported for the review and recommendation of the current evidence, so it does not really change the context here of diabetes."
The review also did not include data from a cardiovascular outcome trial with the lorcaserinBelviq, Eisai), CAMELLIA-TIMI 61, recently reported to the Congress of the European Society of Cardiology (ESC) 2018 and published simultaneously in the New England Journal of Medicine.
Combined with diet and exercise, the drug resulted in modest weight loss compared to placebo and was considered safe even though this trial would also have been considered outside the scope of the study. have established cardiovascular disease, type 2 diabetes, or cardiovascular risk factors.
Surgical approaches "outside the primary care setting"
Although research has shown that bariatric surgical approaches are substantially beneficial in some patients, the recommendations do not address surgical approaches for patients with severe obesity and its comorbidities because they are considered "out of the box" primary care ".
According to her, primary care clinicians "play an important role in identifying potential patients, advising patients to consider an optional surgical procedure and referring them to a specialist or bariatric surgery program. of confidence".
No easy solution for obesity: clinicians must participate for the long term
Doubeni said that behavioral interventions may not be readily available in primary care settings and that clinicians must be able to recognize and document obesity and refer patients to appropriate resources.
The Centers for Disease Control and Prevention's National Diabetes Prevention Program is a promising program that also forms the basis of Medicare's diabetes prevention program, he added.
However, even the best behavioral intervention programs may not be helpful to all patients, writes Yanovski.
For example, 51% of the 1079 patients in the Diabetes Prevention Program – "widely recognized as a global intervention model" – did not achieve their 7% weight loss goal by the end of the 16-year program. sessions.
"There are many reasons for individual variability in response to treatment and although adjustment to treatment is currently imperfect, there is a clear need for complementary therapies for patients who can not achieve and maintain a healthy weight with behavioral treatments alone, "she adds.
Yanovski notes that the evidence review revealed that face-to-face interventions that included at least 14 six-month sessions were the most beneficial. However, such treatment may not be affordable or accessible to all patients.
Those who live in rural areas may lack transportation or full-face programs in person, but distance treatment can improve accessibility for these people, as well as for older people and people with disabilities.
Clinically proven commercial programs are other potential alternatives for some patients.
Clinicians need to know "there are things that work and different things that can be used for different people. Clinicians need to know how important it is and … do it in the long run; It's a chronic condition that people have to be careful about over and over again, "concluded Doubeni.
The authors of the recommendation did not reveal any relevant financial relationship. LeBlanc indicated that his institution received a grant from Merck for a project (unrelated to the subject of this article) on which she was a senior researcher. The other reviewers of the evidence did not reveal any relevant financial relationship. Yanovski reports that his spouse has received research support from his institution (Eunice Kennedy Shriver National Institute of Child Health and Human Development) from Zafgen and Rhythm.
JAMA Posted online September 18, 2018.
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