An Apple a Day

Does the USPSTF Understand What Chronic Means?

The USPSTF is one of those acronyms that provides a good test of sobriety. If you can say it five times quickly, you’re either completely sober or a hopeless health policy geek. It stands for the United States Preventive Services Task Force. Last week, the task force affirmed that primary care providers should refer adults for intensive behavioral therapy (IBT) for obesity if they have a BMI over 30. That’s good advice. But we wonder if the USPSTF understands that obesity is a chronic disease. And if they do, do they know what chronic means?

Milestones in Regarding Obesity as a DiseaseNIH 1998: Obesity Is a Chronic Disease

Obesity is a complex chronic disease. This much has been clear since 1998 when the NIH first issued guidelines on diagnosis, evaluation, and treatment. But ignorance dies hard. Even people who should know better persist in thinking that obesity is simply a bad choice or a behavior.

For example, the American Heart Association lists not having obesity as an “ideal health behavior.” This gaffe is especially embarrassing because AHA joined with the Obesity Society and the American College of Cardiology to issue updated guidelines for managing the chronic disease of obesity in 2013.

One and Done Thinking

So maybe we should not be surprised by the USPSTF excuse for leaving obesity meds out of their new guidelines for preventing the complications of obesity:

Data were lacking about the maintenance of improvement after discontinuation of pharmacotherapy. As a result, the USPSTF encourages clinicians to promote behavioral interventions as the primary focus of effective interventions for weight loss in adults.

The logic gap here is appalling. As a matter of fact, when intensive behavioral support for weight management stops, the excess weight returns. John Foreyt, a distinguished researcher of behavioral interventions for obesity, explained:

We know quite well that continued contact, in some form or another, seems to be the primary key to maintenance. My question is this. Did the new USPSTF guidance also conclude that they couldn’t recommend lifestyle intervention because “data were lacking about the maintenance of improvement after discontinuation of lifestyle intervention”?

Chronic Means That It Keeps Coming Back

This kind of flawed thinking is tough to dislodge. Beliefs that obesity is a mistake that someone can simply erase by losing weight are wrong, but persistent. The truth is, in the absence of a potent intervention, obesity returns every time. The physiology of weight regulation – gone awry in obesity – restores a fat mass that brings other diseases.

This is no different from hypertension – which USPSTF recognizes as a disease that must be identified and treated. And just like obesity, when you stop taking blood pressure meds, hypertension returns.

This is the essence of a chronic disease. It requires chronic disease management. Duh!

Click here for the USPSTF recommendation. For related publications, click here, here,  and here. For reporting from NPR on this, click here.

An Apple a Day, photograph © Еrор Журавлёв / flickr

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September 24, 2018

4 Responses to “Does the USPSTF Understand What Chronic Means?”

  1. September 24, 2018 at 7:11 am, MaryJo said:

    When I first read the USPTF statement, I thought, great, it’s a start (albeit, where were they 40 years ago when the Fogarty Obesity Task Force started making the case that obesity is multifactorial and complex and requires treatment and prevention strategies, accordingly; that is, despite all the research and knowledge, nothing happened in PC offices or, actually, even in tertiary care, where I mainly practiced, and dietitians, like myself, were made to feel hysterical and overly concerned when asked for MD support to help folks struggling). Then, I read that the USPTF idea of ‘intense’ behavioral and lifestyle change management is an initial session with 12 follow-up sessions. Duh, indeed.

    • September 24, 2018 at 7:44 am, Ted said:

      Thanks, Mary-Jo. It’s really tough to overcome the bias that a person’s weight is a simple matter of choice. The reality is that it’s mostly governed by physiology and environment. Most people who have never lived with it just nod and tune out the facts. Just as tough are people who’ve internalized the stigma that’s been heaped on them.

  2. September 24, 2018 at 8:53 am, John DiTraglia MD said:

    Behavioral weight loss interventions to prevent morbidity and mortality

    It’s deja vue all over again.
    Another Yogi Berra quote with metaphysical meaning is “if you don’t know where you’re going, you’ll end up someplace else.” To that I would add the corollary – if you know where your going and it’s a beautiful body, and you know you can’t get there, then you should pick someplace else to go.
    The operation of that corollary is obvious in the title of reports in this week’s Journal of the American Medical Association, (1,2) “Behavioral weight loss interventions to prevent obesity-related morbidity and mortality in adults.” We’re going for weight loss but really we’re only trying to accomplish some impact on the related morbidity and mortality. Well maybe that’s someplace else we can end up.
    Issued by the US Preventive Services Task Force, this updates the last one from 2012, (Notice the difference in title though; that one was – “Screening for and management of obesity in adults” (3) ) and comes to the same conclusion after those 6 years during which time 5 medications were newly approved by the US Food and Drug Administration for long-term management of obesity.
    The way this works is first they make a recommendation based on these guys’ analysis of the evidence and that recommendation is that doctors should offer or refer adults with a BMI of 30 or higher to multicomponent behavioral interventions, and that recommendation gets a “B.” A “B” means that there is moderate certainty of moderate net benefit, with little risk of harm and so they can go ahead and recommend this. The second part is the actual evidence examination that merits this “B.” That article concludes: “Behavioral based weight loss interventions with or without weight loss medications were associated with more weight loss and a lower risk of developing diabetes than control conditions. Weight loss medications, but not behavior-based interventions, were associated with higher rates of harms.” The benefit to other obesity-related outcomes, such as heart disease, high blood pressure, or high cholesterol, is less clear. (5)
    What are behavioral interventions for weight loss? – “Many ways.” The fuzziness of behavioral interventions can be boiled down to trying real hard after you have made the commitment to visit a doctor and shell out for whatever they are. Or ask your insurance to shell out, which may be the real objective of these recommendations. When they say that there is very little or no potential harms of providing behavioral interventions to promote weight loss I don’t think they give adequate importance to the fact that “behavioral” interventions absolutely means that obesity is caused by behavior problems which is not true.

    1. Recommendation statement. JAMA. 2018;320(11):1163-71.
    2. Evidence report. JAMA. 2018;320(11):1172-91.
    3. Moyer VA:US Preventative Services Task Force. Ann Intern Med. 2012;157(5):373-8.
    4. Yanovski SZ. Weight management in adults with obesity. What is a primary care clinition to do? JAMA. 2018;320(11):1111-3.
    5. Jin J. Behavioral interventions for weight loss. JAMA Patient Page. JAMA. 2018;320(11):1210.

  3. September 24, 2018 at 3:41 pm, Sheila D said:

    Really good article. Not only is it important to understand that Obesity is identified as a chronic disease but also important to understand what chronic actually means! Thanks for bringing this to our attention… and reminding us of the complexity of the disease.