Diet and exercise counseling provide 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, which makes recommendations that are often followed by clinicians and health insurance companies alike, released an updated guideline Tuesday on one of the nation's most pressing problems: how to fight the ongoing obesity epidemic estimated to affect one in three adults.
After reviewing the results of 88 clinical trials, a panel maintained a middle-of-the-road C grade for diet and exercise counseling for those classified as normal 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 or not each patient they see could benefit from more intensive weight-loss programs often led by nutritionists who offer a combination of sound advice and regular check ups one-on-one and in group settings.
This higher level attention, often delivered through six-month "comprehensive lifestyle" programs, is already strongly recommended for anyone with cardiovascular risk factors and for those whose body mass index classifies them as obese based on studies that show clear and substantial benefits. 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 evidence, experts were not able to find that behavioral counseling made a huge difference in who, among the overweight and those of normal weight, ended up developing heart disease.
The C rating 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 doctors often don't know what to do 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 that 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.
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