Screening for and Management of Obesity in Adults

November 15, 2012

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Volume 86, Number 10 www.aafp.org/afp American Family Physician 947

Case Study

A 40-year-old woman presents to your office for a routine well-woman examination. She has

no significant medical history. She recently participated in a health fair at work and under-

went free lipid and glucose screening; both levels were within normal limits. Her pulse is

68 beats per minute, her respiration rate is 16 breaths per minute, and her blood pressure is

120/76 mm Hg. She is 170 cm (5 ft, 7 in) tall and weighs 89.8 kg (198 lb). You calculate her

body mass index (BMI) to be 31 kg per m

Case Study Questions

1. Based on the recommendations of the U.S. Preventive Services Task Force (USPSTF), what

is the most appropriate action to take with this patient?

❏ A. Measure her waist circumference to confirm a diagnosis of obesity.

❏ B. Do not initiate a discussion about her weight, because she does not have other

cardiovascular risk factors.

❏ C. Explain the potential health risks associated with obesity, and offer referral to

intensive, multicomponent behavioral interventions.

❏ D. Explain the potential health risks associated with obesity, and offer a behavioral

counseling intervention, as well as a prescription for orlistat or metformin.

2. Which one of the following statements about behavioral interventions for obesity manage-

ment is correct?

❏ A. Individuals who participate in multicomponent behavioral interventions lose an

average of 11.25 to 13.5 kg (25 to 30 lb) over the course of one year.

❏ B. Clinical trials have demonstrated that multicomponent behavioral interventions

decrease the incidence of cardiovascular disease.

❏ C. There is convincing evidence that multicomponent behavioral interventions lead

to clinically important weight loss in individuals who are overweight, as opposed

to obese.

❏ D. The most effective behavioral interventions (i.e., those resulting in the greatest

amount of weight loss) include 12 to 26 sessions in a year.

3. You recommend that your patient consider joining a local, community-based weight-loss

program. The patient agrees, but asks if she should also take a weight-loss medication (orlistat)

that she heard about on the news. Which of the following statements about orlistat are correct?

❏ A. Orlistat in combination with behavioral interventions does not lead to weight loss.

❏ B. The use of orlistat has been associated with severe liver disease in rare cases.

❏ C. There is a lack of long-term safety data available for orlistat.

❏ D. The use of orlistat may increase fasting glucose levels.

Answers appear on the following page.

Screening for and Management of Obesity in Adults

JENNIFER CROSWELL, MD, MPH, Medical Officer, U.S. Preventive Services Task Force Program, Agency for Healthcare

Research and Quality

SHELLY LUGER, RN, MS, Director of Undergraduate Nursing, Mount Marty College; Advanced Leadership Residency,

University of Kansas School of Nursing

▲

See related U.S.

Preventive Services

Task Force Recommen-

dation Statement at

http://www.aafp.org/

afp/2012/1115/od3.html.

Access to the statement

is free and unrestricted.

This clinical content con-

forms to AAFP criteria for

evidence-based continuing

medical education (EB

CME). See CME Quiz on

page 908.

The case study and

answers to the following

questions are based on

the recommendations of

the U.S. Preventive Ser-

vices Task Force (USPSTF),

an independent panel of

experts in primary care

and prevention that sys-

tematically reviews the

evidence of effectiveness

and develops recom-

mendations for clinical

preventive services. More

information on this subject

is available in the USPSTF

Recommendation State-

ment and the evidence

synthesis on the USPSTF

Web site (http://www.

uspreventiveservicestask

force.org). The practice

recommendations in this

activity are available at

http://www.uspreventive

servicestaskforce.org/

uspstf/uspsobes.htm.

A collection of Putting

Prevention into Practice

quizzes published in

AFP

available at http://www.

aafp.org/afp/ppip.

Putting Prevention into Practice

An Evidence-Based Approach

mercial use of one individual user of the Web site. All other rights reserved. Contact copyrights@aafp.org for copyright questions and/or permission requests.

Putting Prevention into Practice

948 American Family Physician www.aafp.org/afp Volume 86, Number 10

◆

November 15, 2012

Answers

1. The correct answer is C. The USPSTF

recommends that all adults be screened for

obesity, and that clinicians offer or refer

patients with a BMI of 30 kg per m

greater to intensive, multicomponent behav-

ioral interventions. Although recent evidence

suggests that waist circumference may be

an acceptable alternative (not addition) to

BMI measurement in some patient sub-

populations, the USPSTF recommendation

is based on BMI calculation alone. Studies

are needed to reassess the best methods for

obesity screening in adults (for example,

waist circumference or waist-to-hip ratio).

The USPSTF recommendation on obesity

applies to all adults, not just a subset of

individuals with known cardiovascular risk

factors. Interventions that combine pharma-

cologic agents (orlistat or metformin) with

behavioral interventions have been shown

to result in weight loss and improvement

in physiologic outcomes. However, there

are concerns about the potential harms of

orlistat, metformin is not approved by the

U.S. Food and Drug Administration (FDA)

for the treatment of obesity, and sufficient

data are lacking for both medications on the

maintenance of improvement after discon-

tinuation of therapy. As a result, the USPSTF

is unable to recommend medication use.

2. The correct answer is D. The USPSTF

found that the most effective behavioral

counseling interventions for obesity man-

agement were comprehensive and of high

intensity (12 to 26 sessions in a year), and

involved multiple behavioral management

activities, such as group and individual ses-

sions, setting weight-loss goals, addressing

barriers to change, and active use of self-

monitoring. Weight-loss outcomes improved

when interventions involved more sessions;

behavioral intervention participants lost an

average of 6 percent of their baseline weight

in the first year with 12 to 26 treatment

sessions compared with little or no weight

loss in control participants. The average

6 percent weight loss for obese individuals

participating in high-intensity, multicom-

ponent behavioral counseling interventions

translates to a loss of about 4 to 7 kg (8.8

to 15.4 lb) over one year. Although the

USPSTF found adequate evidence that

intensive, multicomponent behavioral

interventions for obese adults can improve

physiologic risk factors for cardiovascular

disease, it found inadequate evidence about

the effectiveness of these interventions on

actual long-term cardiovascular health out-

comes. Trial results were not stratified by

BMI category, and the mean BMI across

trials was in the obese range, making it dif-

ficult to ascertain the certainty of benefit

in overweight (BMI of 25 to 29.9 kg per m

)

groups. The USPSTF was unable to examine

differential effects of interventions in over-

weight, as opposed to obese, individuals;

therefore, less is known about the effect of

screening and behavioral counseling inter-

ventions on outcomes for this population.

3. The correct answers are B and C. There

are concerns about the potential harms of

orlistat because of recent FDA reports of

rare severe liver disease and a lack of long-

term safety data. In clinical trials, interven-

tions that combined orlistat with behavioral

interventions resulted in weight loss and

improvement in physiologic outcomes. Orli-

stat led to an average weight loss of about

2.6 kg (5.7 lb), a decrease in waist circum-

ference of 1.9 cm, and a decrease in fasting

glucose level.

Author disclosure: No relevant financial affiliations to

disclose.

SOURCES

U.S. Preventive Services Task Force. Screening for and

management of obesity in adults: U.S. Preventive Services

Task Force recommendation statement. Ann Intern Med.

2012;157(5):373-378.

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(7):434-447. ■