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Why the US Preventive Services Task Force Missed the Boat on BMI



Last week, the US Preventive Services Task Force issued the following recommendation for the screening and management of obesity in adults aged 18 years or older:

“Screen for obesity. Patients with a body mass index (BMI) of 30 kg/m2 or higher should be offered or referred to intensive, multicomponent behavioral interventions.”

This recommendation was supplemented by the thoughtful advice, that obese adults should be offered

“Intensive, multicomponent behavioral interventions for obese adults include the following components”:

  • Behavioral management activities, such as setting weight-loss goals
  • Improving diet or nutrition and increasing physical activity
  • Addressing barriers to change
  • Self-monitoring
  • Strategizing how to maintain lifestyle changes

It is hard to even know where to begin criticizing these recommendations for their inadequacy, inaccuracy, and likely inefficacy.

Never mind that BMI is woefully inadequate in diagnosing individuals who actually have health risks related to their body fat. As regular readers, familiar with our papers on the Edmonton Staging System will be well aware, BMI substantially over-diagnoses ‘obesity’ in those with a BMI greater than 30 while missing millions with body fat-related risk in the BMI 25-30 range.

My recommendation would have been as follows:

“Screen everyone for BMI. In those with BMI greater than 25, screen for obesity related health problems (i.e. determine obesity stage). If problems are found (Stage 1+), consider obesity treatment; if not, then screen them again in a year or so.”

As for the treatment recommendations – how exactly is ‘setting a weight-loss goal’ a ‘behavioral management activity’?

For one, losing weight is NOT a behaviour – it is behaviours that may (or may not) lead to weight loss. Eating breakfast is a behaviour, walking to work is a behaviour, getting more sleep is a behaviour, passing up dessert is a behaviour – losing weight is not.

Secondly, what is it with setting weight-loss goals? Isn’t that the very antithesis of what obesity management should be about. Here we preach that obesity management should be about improving health and well-being rather than simply moving numbers on a scale (see the 5As of Obesity Management) – the Preventive Task Force thinks it is better to focus on a weight-loss goal – go figure!

And what about the recommendation regarding, “Improving diet or nutrition and increasing physical activity”. How do I even know that there is room for improvement, before I have even bothered assessing nutrition or physical activity. Of course, the Task Force simply assumes that if your BMI is greater than 30, then there certainly is room for improving your diet and activity – because, after all, anyone with a BMI greater than 30 probably has a miserable diet and sits on the couch all day (I cannot help wonder what a test for weight bias amongst the Task Force members would reveal).

At least ,”Addressing barriers to change”, certainly sounds good – until you realise that this is not directed at recognising mental health problems, socioeconomic challenges, obesogenic medications or sabotaging spouses and co-workers – no, this is about addressing ‘barriers’ in those with a BMI greater than 30, who don’t want to or don’t happen to see the need to ‘change’ (perhaps simply because they’ve been through this before?).

While I am not going to argue with ‘self-monitoring’, I am far less certain about, ‘Strategizing how to maintain lifestyle change’, largely because I do not like the underlying assumption here, that the problem is simply a matter of ‘lifestyle’.

The very use of the term ‘lifestyle’, not only trivialises the problem (oh, it’s simply a matter of changing my lifestyle – why did you not mention that before – now, that’s easy!) but it also implies that it only takes a change in ‘lifestyle’ for my BMI to drop below 30. Really, all I need now, is a ‘strategy’ and we can all live happily ever after.

Interestingly enough, the recommendations actually go on to discuss ‘Harms and Benefits’:

“Adequate evidence indicates that intensive, multicomponent behavioral interventions for obese adults can lead to weight loss, as well as improved glucose tolerance and other physiologic risk factors for cardiovascular disease.”

That may well be and no one would argue with the potential for these interventions in helping obese adults lose weight – the problem, however, is never losing weight – the problem in obesity management is keeping the weight off. Thus, it may have behoved the Task Force to perhaps mention the importance of long-term management to avoid relapse or recidivism – no indication, either, that sometimes, prevention of further weight gain may well be a reasonable and feasible outcome.

“Inadequate evidence was found about the effectiveness of these interventions on long-term health outcomes (for example, mortality, cardiovascular disease, and hospitalizations).”

If this is indeed true (and I agree, the data on this are limited), then why would you even recommend these interventions to everyone with a BMI over 30 – especially those, who do not appear to have any health problems and are therefore at low risk of mortality, cardiovascular disease and hospitalizations in the first place? (as an aside, the only data on reducing ‘hard endpoints’ with obesity treatments that I know of, come from pharmacological and surgical treatment of obesity in high risk patients – not from ‘intensive, multicomponent behavioral interventions’.)

“Adequate evidence indicates that the harms of screening and behavioral interventions for obesity are small. Possible harms of behavioral weight-loss interventions include decreased bone mineral density and increased fracture risk, serious injuries resulting from increased physical activity, and increased risk for eating disorders.”

So fractures, injuries and risk for eating disorders are the only harms of screening and behavioural interventions? What about frustrations, depression, lower self-esteem, body image issues, and weight cycling? And what about the economic loss from spending good money on useless ‘eat-less-move-more’ strategies?

Often less is more – in this case, not having bothered to release these rather useless ‘recommendations’ would certainly have been More (with a capital ‘M’).

AMS
Edmonton, Alberta

12 Comments

  1. :::LOUD APPLAUSE::::

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  2. Great read Dr. Sharma! Doesn’t the US Preventive Services Task Force know that if their recommendations were that easy we wouldn’t have such an obese society. As a formerly obese individual, who ended up having bariatric surgery, you can attempt to watch what you eat and do all the exercising you want…bottom line is that obesity is a disease and it can’t just be treated at the drop of a hat! You can’t just wake up and decide, “Hey I’m going to change my life today by eating right and exercising”. Sorry it’s just not going to happen. Food is a drug for overweight individuals. It’s like trying to quit smoking…after many years of “enjoying” the habit it’s hard to break it. Unfortunately our country can do what it wants to attempt to help our obese society, but bottom line is unless they want to change they will continue to enjoy food and not exercise.

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  3. Congrats for your post, I would like to quote you

    “The very use of the term ‘lifestyle’, not only trivialises the problem (oh, it’s simply a matter of changing my lifestyle – why did you not mention that before – now, that’s easy!) but it also implies that it only takes a change in ‘lifestyle’ for my BMI to drop below 30.”

    Very well said indeed sir

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  4. Well, I must admit that food has a terribly addictive quality for me that I call “keeping me alive.” All kidding aside — Angela, making blanket statements such as that food is a drug for overweight individuals does not accurately reflect the varying habits and experiences of people of different body sizes. I am overweight (and healthy) and don’t particularly consider myself addicted to food, but I also don’t believe feeding my body when it is hungry is giving in to an addiction. I consider it nourishing and taking care of myself.

    Dr. Sharma — there are days when I just adore you. This is one of them. I was so frustrated to see these recommendations all over the news. I wish the panel had realized that the best thing about beating your head is stopping. Their recommendations merely continue the head-beating.

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  5. Since weight does not equate health, tracking a person’s BMI as a “vital sign” doesn’t make sense and only goes to make the person feel pigeon-holed or stereotyped. If HEALTH is the real concern, I recommend that you investigate Health At Every Size®. NAAFA has created a free brochure geared toward healthcare workers that treat fat patients that can be found at: http://tinyurl.com/7gbevd6

    For more information on Health At Every Size, you can find the guiding principles at the Association For Size Diversity and Health’s website (http://www.sizediversityandhealth.org/content.asp?id=5) or find in-depth research-based information in the book Health At Every Size – The Surprising Truth About Your Weight by Dr. Linda Bacon (http://www.lindabacon.org/HAESbook/).

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  6. Dear Dr. Sharma,

    First, thanks for your masterful critical analysis of these recommendations!

    However, do you really have to “wonder what a test for weight bias amongst the Task Force members would reveal?”

    Their biases are reflected throughout their recommendations–starting with the unwritten assumption that obese patients have somehow managed to avoid numerous previous attempts to lose weight following almost identical advice, which can be found in thousands of articles in hundred’s of magazines every year–do these policy writers never look at magazine covers when standing in market check out lines?

    What would be new, and fresh, and actually helpful would be recommendations for the screening and management of weight bias among weight loss researchers, health care professionals, and weight loss policy writers. The process would start with
    –assessment of weight bias severity followed by
    –“intensive multicomponent behavioral and thought-process interventions” focusing on the following areas of concern:
    1) behavioral management activities directed at acquiring and practicing critical thinking skills,
    2) reading actual research reports of long term outcomes,
    3) reducing arrogant attitudes,
    4) increasing time spent observing actual lives, struggles and lifestyles of obese people,
    5) addressing faulty and harmful assumptions about dieting efficacy,
    6) study the difference between causality and correlation,
    7) closely examine evidence of multidimensional, severe and lasting harm done to patients who have previously (and/or repeatedly) followed similar recommendations yet failed to lose more than a few pounds or managed to lose but regained all (plus extra),
    8) self monitoring for improved understanding about the complexities of different kinds of obesities,
    9) strategizing ways to prevent serious relapse of weight bias when confronted daily with repeated cultural messages repeating similar recommendations as those made by the Task Force.

    I would hope these recommendations would be do-able and helpful, unlike those which merely pay lip service to offering REAL help.

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  7. Dr Sharma’s take on treating the disease of obesity is excellent.

    However, there are also people out there like me:
    BMI 38, but I’m not obese
    That is, I have no health problems (routine doctor checkup.)

    Though Eat Less – Move More is useless for treating the disease of obesity, it has been great for me. Over 4 years I’ve used ELMM to go from BMI 43.4 to BMI 38.

    If you don’t have the disease of obesity, ELMM works well for getting rid of extra fat that’s just a big nuisance.
    While it is important not to try to use ELMM to treat the disease of obesity, it is also important to note that eating less and moving more can be effective in removing extra fat that’s just extra fat, in those people Dr Sharma talks about with high BMI but no disease.

    Of course, if the extra fat isn’t a nuisance, there’s no reason to bother losing it, but I’m happier being a bit smaller. (BTW, my “move more” is just walking, no boot camp sweat)

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  8. Dr. Sharma:
    It ia a breath of fresh air that comes in the form of not everyone can do every thing, I am a good case study in that. Because I gained wieght during group theropy mental health sort of overrides physical health (note I say sort of) because without mental health physical health is irrelavent. The best behavior management is learning proper portion sizes–the Canada Food Guide states that 1/4 cup of nuts is a serving the package now says 1/3 cup is a serving. Maybe we should have the FDA control maximim portion sizes just like it controls medication.

    Learning proper portion size hepled me immeasureably. I recently got a leg brace for my ankle and I can now do the 10,000+ steps and not feel really horrid the next day for it. Other movement with the brace on my foot may be more challenging than ELMM is for most other people.

    In the mean time we obese people need to wait for the next time weight bias ostriches get there heads out of the sand and spew stupidity–that only reinforces other weight bias individuals. What ever works for me may or may not work for the next person if it did work the ostriches would say “see it works,” if it didn’t they “you didn’t try hard enough”.

    thanks for your insight and assistance and a way to sound off.

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  9. Isn’t screening only usefull, if there is also an effective treatment ?
    So, isn’t obesity treatment a lifelong treatment, just like hypertension, diabetes, heartfailure, … and just not one period of intensive behavioral therapy ? and just not a temporary weight loss ? just not a temporary diet ?
    Doesn’t a professional treatment need first of all a correct assessment ? and after assessment , a lifelong individual tailored treatment just like hypertension and diabetes ?

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  10. Dr. Sharma:

    Well put. I often see our nation’s governing bodies making what I call “feel good” recommendations – they feel good that they are doing something to help address our nation’s obesity problem.

    Unfortunately, as you clearly discuss in this post, the recommendations are written by somebody with no experience in obesity management. Perhaps involving an Obesity Medicine Specialist (if this specialty ever gets recognition) or at least a physician skilled in obesity treatment in the drafting of these types of recommendations would be prudent. Or perhaps somebody on the panel should just read your book, “Best Weight.”

    Nonetheless, I do feel that this is an important step. Although the suggestions and methodologies may be flawed, in fact, finally our government is suggesting that we screen for and offer treatment for obesity, with treatments besides surgery. It is nice to see a recommendation for referral to a multidisciplinary treatment facility make it in to a guideline, and a recommendations that all individuals be screened. Although far from ideal, screening with BMI is easy to implement, familiar to primary care doctors, and would at least get treatment to the tip of the iceberg, so to speak.

    Thanks for another great post.

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  11. Great post! I hope you are writing a commentary for publication to go along with this. This really needs to be said. I don’t know what on earthe the USPSTF was even thinking when they made this recommendation.

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