Erin S. LeBlanc, MD, MPH; Elizabeth O'Connor, PhD; Evelyn P. Whitlock, MD, MPH; Carrie D. Patnode, PhD, MPH; Tanya Kapka, MD, MPH
LeBlanc ES, O'Connor E, Whitlock EP, Patnode CD, Kapka T. Effectiveness of Primary Care–Relevant Treatments for Obesity in Adults: A Systematic Evidence Review for the U.S. Preventive Services Task Force. Ann Intern Med. 2011;155:434-447. doi: 10.7326/0003-4819-155-7-201110040-00006
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Published: Ann Intern Med. 2011;155(7):434-447.
Overweight and obesity in adults are common and adversely affect health.
To summarize effectiveness and harms of primary care–relevant weight-loss interventions for overweight and obese adults.
MEDLINE, Cochrane Central Register of Controlled Trials, and PsycINFO from January 2005 to September 2010; systematic reviews for identifying trials before 2005.
Two investigators appraised 6498 abstracts and 648 articles. Clinical trials were included if control groups received minimal interventions. Articles were rated as good, fair, or poor by using design-specific criteria.
One investigator abstracted study characteristics and findings for good- and fair-quality studies; a second checked them.
Behaviorally based treatment resulted in 3-kg (6.6-lb) greater weight loss in intervention than control participants after 12 to 18 months, with more treatment sessions associated with greater loss. Limited data suggest weight-loss maintenance for 1 year or more. Orlistat plus behavioral intervention resulted in 3-kg (6.6-lb) more weight loss than did placebo after 12 months. Metformin resulted in less weight loss. Data on effects of weight-loss treatment on long-term health outcomes (for example, death and cardiovascular disease) were insufficient. Weight-loss treatment reduced diabetes incidence in participants with prediabetes. Effects on intermediate outcomes (for example, lipids and blood pressure) were mixed and small. Data on serious medication harms were insufficient. Medications commonly caused withdrawals due to gastrointestinal symptoms.
Few studies reported health outcomes. Behaviorally based treatments were heterogeneous and specific elements were not well-described. Many studies could not be pooled because of insufficient reporting of variance data. Medication trials had high attrition, lacked postdiscontinuation data, and were inadequately powered for rare adverse effects.
Behaviorally based treatments are safe and effective for weight loss and maintenance.
Agency for Healthcare Research and Quality.
Experts recommend that primary care clinicians offer obese adults interventions that promote weight loss.
In this systematic review of 58 trials, overweight adults in behavioral treatment trials that provided 12 to 26 intervention sessions during the first year lost 9 to 15 lb, whereas control groups lost little or no weight. Adults who received orlistat plus intensive behavioral interventions lost 11 to 22 lb, and those receiving placebo lost 7 to 13 lb.
Behavioral treatment trials studied heterogeneous interventions, and orlistat trials had high rates of attrition.
Behavior-oriented interventions can help overweight adults achieve meaningful weight loss.
KQ 1: Is there direct evidence that primary care screening programs for adult obesity or overweight improve health outcomes or result in short-term (12 to 18 mo) or sustained (>18 mo) weight loss or improved physiologic measures (i.e., glucose tolerance, blood pressure, and dyslipidemia)? a) How well is weight loss maintained after an intervention is completed?
KQ 2: Do primary care–relevant interventions (behaviorally based interventions and/or pharmacotherapy) in obese or overweight adults lead to improved health outcomes (morbidity from diabetes mellitus, cardiovascular disease, cancer, arthritis, asthma, sleep apnea, depression, emotional functioning, physical fitness capacity or performance, physical functioning, disability, mortality)? a) What are common elements of efficacious interventions? b) Are there differences in efficacy between patient subgroups (i.e., age 65 y or older, sex, race/ethnicity, degree of obesity, baseline cardiovascular risk)?
KQ 3: Do primary care–relevant interventions in obese or overweight adults lead to short-term or sustained weight loss, with or without improved physiologic measures? a) How well is weight loss maintained after an intervention is completed? b) What are common elements of efficacious interventions? c) Are there differences in efficacy between patient subgroups (i.e., age 65 y or older, sex, race/ethnicity, degree of obesity, baseline cardiovascular risk)?
KQ 4: What are the adverse effects of primary care–relevant interventions in obese or overweight adults (e.g., nutritional deficits, cardiovascular disease, bone mass loss, injuries, death)? a) Are there differences in adverse effects between patient subgroups (i.e., age 65 y or older, sex, race/ethnicity, degree of obesity, baseline cardiovascular risk status)?
KQ = key question.
Weights are from random-effects analysis. ADAPT = Activity, Diet and Blood Pressure Trial; CV = cardiovascular; DISH = Dietary Intervention to Study Hypertension; DPP = Diabetes Prevention Program; FDPS = Finnish Diabetes Prevention Study; HEED = Help Educate to Eliminate Diabetes; HI = intensive intervention; IV = intervention; LO = brief intervention; NR = not reported; ORBIT = Obesity Reduction Black Intervention Trial; PATH = Physical Activity for Total Health; PREDIAS = Prevention of Diabetes Self-Management Program; Subclinical = trials limited to those with elevated risk but without known disease (prehypertension; impaired glucose tolerance or elevated fasting glucose; borderline high total cholesterol, low-density lipoprotein, or triglyceride levels; low high-density lipoprotein levels; abdominal obesity); TOHP = Trials of Hypertension Prevention; WHLP = Women's Healthy Lifestyle Project; WMD = weighted mean difference.
Weights are from random-effects analysis. Pooled estimates for lipid changes with behavioral interventions were at high risk for reporting bias because lipid outcomes were rarely reported. To convert LDL cholesterol values to mmol/L, multiply by 0.0259. CV = cardiovascular; HEED = Help Educate to Eliminate Diabetes; HI = intensive intervention; IV = intervention; LDL = low-density lipoprotein; LO = brief intervention; NR = not reported; PATH = Physical Activity for Total Health; Subclinical = trials limited to those with elevated risk but without known disease (prehypertension; impaired glucose tolerance or elevated fasting glucose; borderline high total cholesterol, low-density lipoprotein, or triglyceride levels; low high-density lipoprotein levels; abdominal obesity); WHLP = Women's Healthy Lifestyle Project; WMD = weighted mean difference.
Weights are from random-effects analysis. ADAPT = Activity, Diet and Blood Pressure Trial; CV = cardiovascular; DPP = Diabetes Prevention Program; FDPS = Finnish Diabetes Prevention Study; HEED = Help Educate to Eliminate Diabetes; HI = intensive intervention; IV = intervention; LO = brief intervention; NR = not reported; ODES = Oslo Diet and Exercise Study; PATH = Physical Activity for Total Health; PREDIAS = Prevention of Diabetes Self-Management Program; Subclinical = trials limited to those with elevated risk but without known disease (prehypertension; impaired glucose tolerance or elevated fasting glucose; borderline high total cholesterol, low-density lipoprotein, or triglyceride levels; low high-density lipoprotein levels; abdominal obesity); TOHP = Trials of Hypertension Prevention; WHLP = Women's Healthy Lifestyle Project; WMD = weighted mean difference.
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Lewis H. Kuller
Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh
October 11, 2011
Rigorous Standards Need to be Established for Long Term Weight Loss Programs
The US Preventive Services Task Force (USPSTF) evidence update, "Effectiveness of primary care-relevant treatments for obesity in adults: a systematic evidence review for the U.S. Preventive Services Task Force" (1) points a rosy but wrong picture of weight loss interventions. Unfortunately, after 30-40 years of behavioral weight loss programs, the success of long term weight loss is close to null. Successful weight loss is defined as a persistent 10% weight loss(2). Few of the long term studies even reach the 5% that the FDA uses for evaluating drugs. The paper describes 6 studies of longer term weight loss but omits the 3 recent major studies - Action for Health in Diabetes (Look AHEAD), Diabetes Prevention Program (DPP) and the Women on the Move Through Activity and Nutrition (WOMAN) Study.
The Women's Healthy Lifestyle Project (WHLP) was a prevention of weight gain trial and not a weight loss study. The Trials of Hypertension Prevention Study (TOHPS) Phase II reported 0.2 kg weight loss in the intervention at 36 months, the Trial of Nonpharmacological interventions in the Elderly (TONE) 4.7 lbs at 30 months, the Dutch Weight Loss Study 2.4 kg at 2 years only, Finnish Diabetes Prevention Trial 3.5 kg at 2 years and the Hypertension Prevention Trial 1.6 kg at 3 years in the intervention group, overall not very impressive.
The 4 year Look AHEAD results (3) reported a 4.7% weight loss at 4 years, the overall 10-year DPP (4) about 2 kg and the WOMAN Study final results, 3.4 kg at 48 months(5).
There is a serious obesity epidemic. It is very bad policy to assume a failure of long term weight loss as really a "success." We need to stop doing the same interventions with little modification over and over again, admit defeat and support new research approaches for long term successful weight loss. Rigorous standards need to be established for long term weight loss programs. There is a very high likelihood of a very expensive boondoggle.
Kuller, MD, DrPH Professor Emeritus Department of Epidemiology Graduate School of Public Health University of Pittsburgh
1. LeBlanc ES, O'Connor E, Whitlock EP, Patnode CD, Kapka T. Effectiveness of primary care-relevant treatments for obesity in adults: a systematic evidence review for the U.S. Preventive Services Task Force. Ann Intern Med. 2011;155:434-47.
2. Wing RR, Hill JO. Successful weight loss maintenance. Annu Rev Nutr. 2001;21:323-41.
3. The Look AHEAD Research Group. Long-term effects of a lifestyle intervention on weight and cardiovascular risk factors in individuals with type 2 diabetes mellitus. Arch Intern Med. 2010;170:1566-75.
4. Diabetes Prevention Program Research Group. 10-year follow-up of diabetes incidence and weight loss in the Diabetes Prevention Program outcomes study. Lancet 2009;374:1677-86.
5. Kuller LH, Gabriel KK, Kinzel LS, Underwood DA, Conroy MB, Chang Y, et al. The Women on the Move Through Activity and Nutrition (WOMAN) study: final 48-month results. Obesity. 2011, In Press.
Alan, Moses, Corporate Vice President and Global Chief Medical Officer, Yehuda Handelsman (President, AACE), and Daniel Einhorn (Immediate-Past President, AACE)
Novo Nordisk Inc, Princeton, NJ, USA
October 28, 2011
Screening for diabetes: a call to action
To the editor: The obesity review for the U.S. Preventive Services Task Force (USPSTF) emphasizes that behavioral interventions producing weight loss can reduce type 2 diabetes mellitus (T2DM) incidence by up to 50% (1). We support the screening recommendations for obesity, but believe there are discrepancies between these guidelines and current (2008) USPSTF recommendations for T2DM (2). Namely, USPSTF recommends screening for obesity, despite no evidence of long-term health gains from randomized prospective screening trials (1), but ignores the clear epidemiologic and etiologic relationship between obesity and T2DM by advocating screening for T2DM in asymptomatic individuals only when systolic blood pressure is >135 mmHg (2). Importantly, risks attributed to obesity or, indeed, multiple other risk factors associated with T2DM development are not considered (3).
The Centers for Disease Control and Prevention (CDC) estimates that 26 million Americans have diabetes (1/3 undiagnosed) while 79 million have prediabetes, which combined, comprise 1/3 of the U.S. population. Given that >80% of patients with T2DM are overweight/obese, USPSTF should reconsider its position on diabetes screening (2) and, consistent with rationale behind their obesity screening recommendations, recognize that beneficial outcomes (weight loss and prevention or delay of T2DM) warrant screening.
Various organizations including the American Diabetes Association (ADA) and American Association of Clinical Endocrinologists (AACE) have T2DM screening guidelines based on multiple risk factors including overweight/obesity that go beyond USPSTF recommendations (3,4). Comparison of ADA and AACE with USPSTF screening criteria revealed that using USPSTF guidelines resulted in fewer individuals being eligible for T2DM screening with substantial reductions in new diagnoses (3,4). Along with assessing blood pressure, lipids, and other risk factors during routine provider visits, opportunistic glycemic screening using A1c or FPG is simple and low-cost with minimal risk for harm. At-risk individuals can be counseled on lifestyle modification (similar to USPSTF obesity recommendations) and retested periodically, while diagnosed individuals can be treated earlier than currently occurs. Since publication of USPSTF screening recommendations for T2DM (2), long-term follow-up results from DCCT-EDIC and UKPDS have confirmed that early diagnosis and treatment can reduce risks of chronic diabetes complications.
Since T2DM has reached epidemic proportions and a U.N. resolution recognizes diabetes as a chronic, debilitating and costly disease that adversely impacts families, countries and the world (5), we urge USPSTF to consider evidence from randomized trials and expert guidelines from various professional societies, and update its recommendations to include opportunistic screening for T2DM in at-risk individuals.
1. LeBlanc ES, O'Connor E, Whitlock EP, Patnode CD, and Kapka T. Effectiveness of primary care-relevant treatments for obesity in adults: a systematic evidence review for the U.S Preventive Services Task Force. Ann Intern Med 2011;155:434-47.
2. U.S. Preventive Services Task Force. Screening for type 2 diabetes mellitus in adults: U.S Preventive Services Task Force recommendation statement. Ann Intern Med 2008;148:846-54.
3. American Association of Clinical Endocrinologists. Medical guidelines for clinical practice for developing a diabetes mellitus comprehensive care plan. Endocr Pract 2011;17 (Suppl. 2):1-53.
4. Sheehy AM, Flood GE, Tuan W-J, Liou J, Coursin DB, and Smith MA. Analysis of guidelines for screening diabetes mellitus in an ambulatory population. Mayo Clin Proc 2010;85:27-35.
5. United Nations Resolution 61/225: World Diabetes Day. http://www.worlddiabetesfoundation.org/media(3892,1033)/UNR_media_kit_0407.pdf. Accessed October, 19, 2011.
Alan Moses: Employee and share holder, Novo Nordisk. Yehuda Handelsman: Research grants: Abbott, Boehringer, Ingelheim, ConjuChem, Daiichi Sankyo, Inc, GlaxoSmithKline, Novo Nordisk, sanofi-aventis, Takeda Pharmaceuticals, Xoma, Tolrex; Consultant: Abbott, Amylin, Daiichi Sankyo, Inc, Gilead, GlaxoSmithKline, Genentech, Merck, NovoNordisk, Sanofi, Takeda, Tolrex; Speaker: AstraZeneca, Boehringer Ingelheim, Bristol-Myers Squibb, Daiichi Sankyo, Inc, GlaxoSmithKline, Merck, Novo Nordisk. Daniel Einhorn: Shareholder: Mannkind, Halozyme, Freedom-Meditech; Clinical research: Eli Lilly, Sanofi-Aventis, Johnson & Johnson, Astra Zeneca, Boehringer-Ingelheim; Advisor: Novo Nordisk, Amylin; Speaker: CME only.
Erin S., LeBlanc, MD, MPH, Elizabeth O' Connor, PhD
Center for Health Research, Kaiser Permanente, Portland, OR
November 21, 2011
We thank Dr. Kuller for his comment. We conducted this systematic review for the USPSTF to use to make its recommendation about screening and treatment of adult obesity. The USPSTF recently posted a draft recommendation for public comment, but has not yet released its final recommendation.
With regards to the articles in question, we excluded the Look AHEAD and WOMAN studies because the control groups received more than a minimal intervention, which was outside the focus of our review. Our systematic review summarized the data regarding the effectiveness of weight loss interventions compared with no intervention or usual care. We also excluded the 10-year DPP data because they were derived from a cohort design, and were thus excluded from our review. The long-term weight loss data in the intervention groups outlined by Kuller are consistent with our review. In those same studies, the control groups lost minimal to no weight or gained weight (nearly 2 kg in TOHPS phase II and HPT). Therefore, when pooled, the amount of weight loss in the intervention groups was statistically significantly greater than that in the control groups.
Erin S. LeBlanc, MD, MPH Elizabeth O' Connor, PhD Center for Health Research Kaiser Permanente Portland OR
Hugh, Mann, Physician
Eagle Rock, Mo 65641
March 11, 2012
What is health?
Health is metabolic efficiency. Sickness is metabolic inefficiency. Nobody is totally healthy or totally sick. Each of us is a unique combination of health and sickness. And each of us has a unique combination of abilities and disabilities, both emotional and physical.
As we grow up, we learn that we are loved for our abilities but hated for our disabilities. This happens at home, at play, at school, and at work. Sometimes, this even happens with our doctors, especially if our disabilities mystify them or remind them of their own disabilities.
So, we try to hide our disabilities from people and from ourselves. This charade undermines our relationships and our self-esteem. We learn to fear society and hate ourselves.
Self-hatred is the most debilitating sickness. It interferes with our ability to seek and accept help. And everybody needs help. How do we free ourselves from self-hatred?
First, we reclaim our disabilities, whether society accepts them or not. This means that we learn to accept ourselves. Then, we cope with our disabilities. This means that we learn to take care of ourselves.
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