Should doctors prescribe exercise and diet changes to patients who aren’t obese?

Diet and exercise counseling provides a “positive but small” effect in preventing cardiovascular disease for otherwise healthy adults, according to a new recommendation from one of the nation’s most influential health care organizations.

The U.S. Preventive Services Task Force, whose guidelines are often followed by clinicians and insurance companies alike, released an updated guideline Tuesday on one of the nation’s most pressing problems: How to reverse an ongoing obesity epidemic that’s estimated to affect one in three adults. Rather than simply treating obesity, medicine is increasingly taking a preventive approach which attempts to instill healthier habits early and stop weight gain from occurring.After reviewing the results of 88 clinical trials, a panel maintained a middle-of-the-road “C” grade for diet and exercise counseling for people classified as normal weight or overweight who have no known risk factors for heart disease such as hypertension, high blood sugar levels, elevated blood cholesterol or diabetes.

The rating leaves it up to individual doctors to decide whether each patient could benefit from more intensive weight-loss programs often led by nutritionists, who offer a combination of sound advice and regular check-ups in a one-on-one or group setting.

Such efforts, often delivered through six-month “comprehensive lifestyle” programs, are already strongly recommended for anyone with cardiovascular risk factors and for those whose body mass index classifies them as obese. In some cases, for example, diabetic patients are able to stop taking medications after moving toward healthier food choices and becoming more active.

But after looking at the current body of evidence, experts were not able to authoritatively determine that among overweight or normal-weight people,, behavioral counseling made a huge difference in preventing heart disease.

The “C” grade is important for another big reason: The Affordable Care Act requires all health insurance companies to cover preventive services receiving an A or B rating from the task force. So, while insurance companies are currently required to cover weight loss counseling for those who are already obese, that will not be the case for those who are merely overweight. This is despite the fact that the American Heart Association recommends such counseling for both weight categories.

Dr. Carol Mangione, a task force member and practicing internal medicine specialist who teaches at the UCLA David Geffen School of Medicine, said the letter grade should not be taken as evidence that diet and exercise changes are not beneficial or critical in fighting the nation’s obesity epidemic. It’s just that, when looking only at the evidence, other choices, such as quitting smoking, deliver a larger benefit and thus get a higher grade.

As to the fact that a C grade is one shy of insurance coverage requirements? Though the task force is seen as the arbiter of what gets covered and what does not, that’s not part of the evaluation process.

“We look at the clinical evidence but we don’t consider insurance coverage at all,” Mangione said.

Because it looks at weight through the lens of cardiovascular disease, the recommendation, noted Dr. James Sallis, a well-known behavioral medicine researcher at UC San Diego, is far from the last word on who should be told to enroll in a comprehensive lifestyle program and who shouldn’t.

“The problem is, diet and exercise specifically are related to many different diseases. Cardiologists don’t pay much attention to cancer and osteoporosis and depression, but they are all affected by obesity. Recently, as an example, there was a very large study that linked physical activity levels to 13 different cancers,” Sallis said.

The bigger problem, he added, is that many doctors don’t know what to do, beyond advocating for a plant-based diet more regular exercise, when they encounter a patient who is overweight and at risk of eventually becoming obese. Often, he said, they send patients to gyms and other self-directed resources even though evidence shows that the best results are obtained from the kinds of programs which help people set specific goals, have accurate ways to track progress toward those goals and have some sort of mechanism, such as group meetings where results are shared, to provide accountability.

Creating a link between doctors and these more-proven options, he said, is what’s needed in order to reverse the obesity epidemic, and that’s why the C grade was a little disappointing.

“A C recommendation is not going to stimulate much change. The way our system works, if they don’t have a diagnosis that would lead to coverage, then they are going to have to pay out of pocket. When patients have to pay out of pocket, they’re less likely to follow a doctor’s recommendations,” Sallis said.

But Dr. Kristin Hampshire, a family medicine practitioner at Sharp Rees-Stealy Medical Group, said breaking patients down by body mass index, which is the main way that medicine decides who is obese and who isn’t, is not 100 percent-accurate.

“There are some patients who are in fact doing everything right, and that number of the scale refuses to budge.It’s important to emphasize that the health benefits of healthy lifestyle choices are tangible no matter what your weight is,” Hampshire said.

There is also huge variation from doctor to doctor when it comes to prevention. Some may make sure to mention that as-yet-unscheduled colonoscopy every time they come in for a checkup while others may let it ride. So, publishing guidelines for doctors, as the task force does regularly, may or may not be universally embraced.

Hampshire said her medical group has tried to standardize its clinical practices across its 500 doctors and 2,800 employees working in 22 medical offices, but, in the end, the amount of attention paid to helping patients change their healthy living patterns can come down to whether a physician has taken this kind of action in his or her own life.

“Most of the problems that we’re seeing our patients for relate in some way to lifestyle choices. I think it depends so much on the doctor and their personal interest, in the continuing education they’ve taken throughout their careers, and their own lifestyles,” Hampshire said.

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