The US Preventive Services Task Force (USPSTF) is a team of volunteer experts from various primary care medicine and nursing fields. They identify big medical problems, review the research, and translate it into action plans (called practice recommendations) for doctors like me.
Just this fall, they tackled obesity, with the goal of identifying effective ways we in primary care can help people to lose weight.
And it's not about aesthetics. This is about disease prevention, especially diabetes, high blood pressure, and heart disease, which are particularly associated with obesity.
They were NOT looking at surgeries or other procedures, only research trials involving either behavioral or medication-based weight loss programs.
The task force analyzed 89 behavioral weight loss program trials from all over the world, and these included participants of both genders as well as many racial and ethnic groups, with ages between 22 and 66, and body mass index between 25 and 39.
What was involved in a behavioral weight loss program?
The programs studied lasted between 12 and 24 months, and involved at least 12 sessions (face-to-face, group meetings, or web-based). A variety of specialists were involved (behavioral therapists, psychologists, registered dietitians, exercise physiologists, lifestyle coaches, as well as physicians) who provided counseling on basics like nutrition, physical activity, and self-monitoring, as well as psychological components like identifying obstacles, planning ahead, problem solving, and relapse prevention. Email, telephone, and/or peer support were typically included. Basically, these are intensive programs that focus on lasting diet and lifestyle change.
And intensive diet and lifestyle programs work well for weight loss. Participants had significant weight loss compared to controls, averaging between 1 and 20 pounds, with an average weight loss of 5 pounds overall, and were more likely to have lost 5% of their total body weight at 12 to 18 months. Thirteen trials looked at diabetes risk, and pooled results showed that participants had a significantly lower risk of developing diabetes.
Here's the most important part: the risks of participating in these studies were minimal. This is a major plus to behavioral interventions: no side effects or drug complications.
How did behavioral programs compare with medications?
That is considerably different from studies featuring weight loss medications. Thirty-five studies looking at a variety of medications (like liraglutide, lorcaserin, naltrexone and bupropion, orlistat, and phentermine-topiramate) had stringent inclusion criteria and high dropout rates. Why? Because of the many medical contraindications of some of these medications, and the side effects, some quite serious.
Yes, the medication studies demonstrated significant weight loss, ranging from 2 to 13 pounds. But in the end, the USPSTF has to weigh effectiveness as well as potential risks, and they concluded that "intensive, multicomponent behavioral interventions in adults with obesity 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 …… and that the harms of intensive, multicomponent behavioral interventions (including weight loss maintenance interventions) in adults with obesity are small to none."
Basically, intensive behavioral programs aimed at lasting lifestyle changes work well for weight loss, and are extremely low-risk to boot.
So where can you sign up for such programs?
Okay, here's where the gap between science and practice comes in.
Few of these behavioral weight loss programs exist, and not everyone meets the criteria for insurance to cover them. So for most people, unless they can afford to pay out of pocket, these programs are only available through research studies.
For example, the Diabetes Prevention Program (DPP) is an excellent intensive lifestyle change behavioral weight loss program that has been studied for literally decades and works very well. It's a year-long commitment including 22 learning sessions (in-person or online) and frequent contact with a lifestyle coach. Insurance will cover this program for people who have a BMI over 25 and a confirmed diagnosis of prediabetes. Not diabetes, only prediabetes. The DPP curriculum is available for free on the Centers for Disease Control (CDC) website. Anyone could establish a program.
But a program has to meet a lot of requirements over a significant amount of time before it's officially recognized by the CDC, and insurance companies won't cover a program until it's recognized by the CDC. Even then, reimbursement rates can vary. As a result, there aren't many of these programs up and running, but there are some. To find a recognized DPP program in your state or online, check out the CDC's registry.
Many hospitals offer less intensive, shorter behavioral lifestyle change programs, but these are pay-out-of-pocket and generally cost upwards of $500.
What can you do if you can't access a behavioral weight loss program?
You can work with your doctor and create your own program by consulting with relevant specialists (for example, a nutritionist, personal trainer, and therapist), following your own progress (for example, at the doctor's office or using an app), and arranging your own peer support (ask friends and family to join you on your health journey, or join a group like Weight Watchers). I have had patients who have succeeded in making lasting lifestyle changes — including weight loss — using this approach.
Mobile phone apps are a relatively new but promising tool. In one 2015 research review, studies of various weight loss phone apps, used for six weeks to nine months, showed a significant average weight loss of 2.2 pounds. Some free, widely available apps include MyFitnessPal, Lose It, Noom, Weight Watchers, and Fooducate (note that these were not necessarily the ones studied in that review article).
I am hopeful that soon, guidelines-based intensive lifestyle change programs will become more widely accessible to everyone who needs this support.
There are books that can help you. I have written an evidence-based book expressly for self-guided diet and lifestyle change, Healthy Habits for Your Heart.
But my book is not the only one; other quality examples address behavioral factors for lasting lifestyle change:
Disease-Proof by David Katz, MD, MPH
The Spectrum by Dean Ornish, MD
Eat, Drink, and Be Healthy by Walter Willet, MD, DrPH
Smart at Heart (for women) by Malissa Wood, MD, FACC