Last month the U.S. Preventive Services Task Force (USPSTF) posted a draft recommendation statement and evidence review calling on clinicians to refer patients with obesity to intensive and multicomponent behavior programs. The same is recommended for adults with BMI 25
to 29.9, with hypertension and/or dyslipidemia or with abnormal blood glucose levels
The new draft recommendation affirms its 2012 final decision on screening for obesity and intensive behavioral interventions and marks the third time the USPSTF has looked at the disease in 15 years. Studies examining bariatric surgery and nonsurgical weight loss devices like intragastric balloons were considered “outside the scope of the primary care setting.”
“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 Task Force chair David C. Grossman, M.D., M.P.H. in a news release.
A story about the recommendations that appeared February 21 on the AAFP website sparked controversy after a family physician commented that he recommends his patients avoid bariatric surgery and weight control medication in most cases.
"Medications for weight loss don't make any logical sense to me," the family physician said in the article. "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."
The doctor also said that he generally recommends against bariatric surgery, except in patients with severe obesity 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."
Neil Floch, MD, a member of ASMBS, took to Twitter to express his dismay at the comments.
Dr. Floch tweeted, “As responsible physicians we would all hope that behavior change and intense therapy were available and successful for all with obesity but medical evidence DOES NOT support such methods alone. Shame on AAFP for discounting medical and surgical treatment.”
Ted Kyle, RPh, MBA who founded ConscienHealth to help experts and organizations work for evidence-based approaches to health and obesity, was “shocked” and “profoundly sad” by the comments.
Kyle wrote a blog about it and tweeted that it was “genuinely shocking to see the AAFP dispense bias and misinformation about obesity instead of facts.
Jennifer Frost, MD, medical director of the AAFP's Health of the Public and Science Division, responded on the organization’s website on March 6 with a guest editorial to clarify the AAFP’s position, stating the group has endorsed the management guidelines developed by the American College of Cardiology, the American Heart Association and the Obesity Society, which among its recommendations includes:
- 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.
Dr. Frost said the family physician quoted in the article was speaking for himself and not the AAFP and that the USPSTF “task force considered surgical interventions and nonsurgical weight loss devices to be outside the scope of the primary care setting.”
According to Dr. Frost, the AAFP will be providing comment on the new draft recommendation following its Subcommittee on Clinical Preventive Services’ evaluation of the 2018 evidence review. She says “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.”
The draft recommendation, “Weight Loss to Prevent Obesity-Related Morbidity and Mortality in Adults: Behavioral Interventions,” and corresponding draft evidence review are available for public comment on the USPSTF website until March 19, 2018.
Successful intensive behavioral programs “take more time than a single conversation with a health care professional,” according to a
USPSTF-issued statement, and involve a range of activities that may take place outside doctors’ offices including “group sessions (at least 12 sessions or more in the first year), helping people make healthy eating choices, encouraging increased physical activity, and helping people monitor their own weight.” However, “the only intervention component significantly related to greater weight loss was any use of group sessions,” according to the Task Force.
With regard to pharmacotherapy, while the Task Force’s evidence review revealed that interventions combining pharmacotherapy with behavioral interventions are “associated with greater weight loss and weight loss maintenance over 12 to 18 months compared with interventions that combined behavioral interventions with placebo,” the USPSTF did not make a recommendation supporting the use of medication as a secondary intervention noting a lack of evidence demonstrating weight loss maintenance once treatment stops.