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November 2018

Treating Obesity—Moving From Recommendation to Implementation

Author Affiliations
  • 1The Brown School, Center for Obesity Prevention and Policy Research, Washington University in St Louis, St Louis, Missouri
  • 2Department of Medicine, The School of Medicine, Washington University in St Louis, St Louis, Missouri
  • 3Department of Medicine, Welch Center for Prevention, Epidemiology & Clinical Research, Johns Hopkins Medical Institutions, Baltimore, Maryland
  • 4Department of Health, Behavior, and Society, Welch Center for Prevention, Epidemiology & Clinical Research, Johns Hopkins Medical Institutions, Baltimore, Maryland
  • 5Department of Acute and Chronic Care, Welch Center for Prevention, Epidemiology & Clinical Research, Johns Hopkins Medical Institutions, Baltimore, Maryland
JAMA Intern Med. 2018;178(11):1447-1449. doi:10.1001/jamainternmed.2018.5259

Today 39.6% of adults in the United States are obese, placing them at high risk for chronic disease-related morbidity and mortality.1 Behavioral weight management is a proven treatment for obesity, with significant benefits associated with a weight loss of 5% to 7%.2 The US Preventive Services Task Force (USPSTF) recommendation for “Behavioral Weight Loss Interventions to Prevent Obesity-Related Morbidity and Mortality in Adults,”3 supported by an evidence report and systematic review,4 provides evidence for effective programs to reverse obesity and reduce risk for negative health outcomes. The current USPSTF statement “recommends that clinicians offer or refer adults with a body mass index (BMI) of 30 or higher…to intensive, multicomponent behavioral interventions (B recommendation).”3 These interventions “can lead to clinically significant improvements in weight status and reduce the incidence of type 2 diabetes among adults with obesity and elevated plasma glucose levels.”3 This statement updates the 2012 USPSTF recommendation5 by further articulating core program elements and structure needed for effective counseling and impact. However, a recent study by Fitzpatrick and Stevens6 reported that obesity management in primary care settings remains suboptimal, with underdiagnoses of obesity and declines in weight management counseling from 33% in the 2008-2009 period to 21% in the 2012-2013 period.6 Despite evidence that intensive behavioral interventions work, most patients will not receive care that complies with that evidence. A critical priority then is how to promote the implementation and dissemination of evidence-based obesity interventions.

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2 Comments for this article
We need a clearer message
Richard Cooper, MD | Loyola University Medical School
I'm a little surprised to see "increasing physical activity" continue to be listed as an "effective intervention". At this point the evidence in quite clear that compensatory intake, in addition to the very small number of calories most people expend, combine to make changes in activity ineffective. This has even been the subject of several articles in the press recently - ie, the NY Times. Why are CDC and guidelines lagging behind the lay press? There has, of course, been vigorous push-back from the food and beverage industry, especially through their paid consultants in the field, who promote exercise programs to blunt the public health message.

There is only one way to lose weight - consume less food. We have wasted a lot of time and energy avoiding that message. Of course these guidelines emphasize change in eating behavior but this message is very difficult to implement and we need every ounce of clarity possible. So to speak.
Exercising is the key to a longer life
Peter Still, PhD | Not Affiliated
I would like to comment absit the earlier comment that argued that exercising should not be on the list of recommendations for obese people. I would like to stress in response that studies have shown consistently that longevity and the capacity to lead an active life are more closely correlated to physical activity than to weight. In other terms, a physically active obese person can expect to live a similar life to a non obese person who also exercises. However, a non-physically active obese person can expect to live a significantly shorter and worse life. In addition, studies have demonstrated that exercise can speed up weight loss when combined with the appropriate food. Thus, exercising should be at the top of the list, together with dieting for those looking to lose weight.

Consistently, studies have also shown that eating less absolutely never ever works for obese people. Obese people who shed weight by eating calorie restricted diets almost always bounce back and worse. The two methods that have shown results are (1) surgical, with a stomach ring, and (2) dieting which involves changing food habits, typically for  obese people with type 2 diabetes it means a ketogenic diet. Other diets are also available, including going vegan and going off refined products.