USPSTF: Optimal Behavioral Interventions for Obese Adults

After a review of the evidence, the US Preventative Services Task Force (USPSTF) recommended that primary care physicians prioritize behavioral interventions over medical interventions for obese adults.

Multi-component, intensive behavioral interventions led to clinically significant weight loss with little risk of harm. Drug therapy also resulted in clinically significant weight loss, but the evidence was weaker and the risk of harm appeared to be greater, said the task force in the paper, published in JAMA.

"The USPSTF recommends that clinicians suggest or refer adults with a body mass index [BMI] 30 or more to intensive multicomponent behavioral interventions. (Recommendation B). "The task force did not review evidence on surgical procedures because it was considered" outside the primary care setting ".

The "B" level of the USPSTF scheme means "a great deal of certainty that the net benefit is moderate, or a moderate certainty that the net benefit is moderate to substantial" and that physicians should "offer or provide this service ".

From 2013 to 2014, the prevalence of obesity in the United States was greater than 35% among men and 40% among women, noted the working group. One in 13 Americans was severely obese and, according to 2011-2014 data from the National Center for Health Statistics, the age-adjusted prevalence of overweight or obese people is 72.8% for men and women. 66.2% among women.

The USPSTF recommendations were based on a systematic review of 122 randomized clinical trials involving more than 62,000 participants, as well as two observational studies involving more than 200,000 individuals. Compared with controls, participants in behavioral interventions had an average weight loss greater than 12-18 months (-2.39 kg, 95% CI -2.86-1.93) and less weight gain (-1.59 kg, 95% CI -2.38 to -0.79).

"Overall, the trials showed no serious damage, and most trials observed no difference in the rate of adverse events between intervention groups. and the control groups, "said the working group.

Drug-based weight loss studies have also shown a weight reduction greater than that of placebo between 12 and 18 months (mean difference in weight change from -1.0 to -5.8 kg) and better maintenance of weight loss over 12 to 36 months 3.5 kg). However, "rates of adverse events were high in intervention groups and placebo groups by 12 months, with 80% to 96% of participants having an adverse event in the drug group versus 63% to 94% % in the placebo group ". I said.

"The higher rate of adverse events in the drug groups resulted in higher dropout rates than in placebo groups.The other limitations of pharmacotherapeutic studies include a small number of trials for each drug, methodological variability, missing data, poor follow-up limited applicability (participants met narrowly defined inclusion criteria). "

Most of the behavioral interventions contemplated by the USPSTF lasted 1 to 2 years and the majority had 12 or more sessions the first year. One third experienced a "basic" phase ranging from 3 to 12 months, followed by a maintenance phase of 9 to 12 months. Most also encouraged weight self-monitoring and provided tools to support weight loss or maintenance, such as pedometers, food scales or exercise videos.

In an accompanying editorial, Susan Yanovski, MD, of the National Institute of Diabetes and Digestive and Kidney Diseases in Bethesda, Md., Pointed to some limitations of examining evidence by the USPSTF: "Because the recommendations diseases for which weight loss is part of the management of the disease, some long-term clinical trials conducted in patients with type 2 diabetes or cardiovascular disease n & # 39; 39 were not included. "For example, the AHEAD Look Test was omitted.

"While this approach may improve the specificity of the results for patient populations without apparent obesity-related illness, this means that important data on the effect of weight management interventions among the"

Another important limitation, she said, was the decision not to review the surgeries. There is growing evidence that bariatric surgery brings substantial benefits, including not only weight loss, but also the prevention and resolution of type 2 diabetes. "Although primary care clinicians do do not perform bariatric surgery, they play an important role in identifying patients likely to benefit from it, advising patients to consider surgery as an option and referring to a specialist

In a second editorial, Debra Haire-Joshu, PhD, of the University of Washington at St. Louis, and Felicia Hill-Briggs, Ph.D., of Johns Hopkins in Baltimore, stated that primary care physicians interventions, there must also be systems in place to ensure that they are provided to the patients who need them.

"The USPSTF's recommendation identifies the common and essential components for delivering effective behavioral weight loss interventions in adults. However, there is a need to better align these recommendations with the structure needed to implement them." in many primary care settings and lay interventionists play a role in providing behavioral weight loss interventions, which requires us to expand the reimbursement to those who can implement treatment based on proofs. "

In addition, Haire-Joshu and Hill-Briggs wrote that "the development of obesity over the course of life and the propensity to regain weight after successful weight loss also require multisectoral partnerships and broad approaches to public health to fight against obesity. to gain and maintain a healthy weight beyond primary care. "

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