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EFFECTIVENESS OF PRIMARY CARE-RELEVANT TREATMENTS FOR OBESITY IN ADULTS: A SYSTEMATIC EVIDENCE REVIEW FOR THE U.S PREVENTIVE SERVICES LEBLANC ES, O’CONNOR E, WHITLOCK EP, PATNODE CD, KAPKA T ANN INTERN MED. 2011;155:434-4 FUNDING: AGENCY FOR HEALTHCARE RESEARCH AND QUALITY. Terry Son - PowerPoint PPT Presentation
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EFFECTIVENESS OF PRIMARY CARE-RELEVANT TREATMENTS FOR OBESITY IN ADULTS: A
SYSTEMATIC EVIDENCE REVIEW FOR THE U.S PREVENTIVE SERVICES
LEBLANC ES, O’CONNOR E, WHITLOCK EP, PATNODE CD, KAPKA T ANN INTERN MED. 2011;155:434-4
FUNDING: AGENCY FOR HEALTHCARE RESEARCH AND QUALITY
Terry SonMercer UniversityOctober 28, 2011
OBJECTIVE
To summarize the effectiveness and harms of primary care-relevant weight-loss interventions for overweight and obese adults
BACKGROUND
Obesity (BMI > 30 kg/m2) is high in the U.S. exceeding 30% in most age and sex-specific groups
2007-2008—32% men and 36% women were obese Prevalence of obesity and of overweight have
increased by 134% and 48%, respectively since 1976-1980
http://resources0.news.com.au/images/2011/03/30/1226030/4795
BACKGROUND
Obesity is associated with: increased mortality, especially in adults <65 years Coronary heart disease Type 2 diabetes Certain types of cancer
http://medicineworld.org/news/news-archives/438941683-April-15-2009.html
BACKGROUND
In 2003, the U.S. Preventive Services Task Force (USPSTF) recommended that clinicians:
Screen all adults for obesity and Offer intensive counseling and behavioral
interventions
http://neuroscene.com/wp-content/uploads/2011/08/obesity.jpg
BACKGROUND
According USPSTF: Insufficient evidence to recommend for or
against moderate or low-intensity counseling together with behavior interventions to promote sustained weight loss in obese adults
Evidence was insufficient to recommend for or against counseling of any intensity and/or behavioral interventions to promote sustained weight loss in over-weight adults
BACKGROUND
The study did a systematic review to help update the recommendations
Developed an analytic framework with 4 key questions
KQ1 Asked whether primary care screening programs to identify obesity or over-weight in adults improved health or physiologic outcomes or resulted in weight loss.
KQ2 Asked whether primary care weight-loss interventions (behaviorally based with or without pharmacologic adjuncts) improved health outcomes.
KQ3 Asked whether primary care weight-loss interventions (behaviorally based with or without pharmacologic adjuncts) resulted in short-term (12 to 18 months) or long term (>18 months) weight loss, with or without improved physiologic measures
KQ4 Asked whether primary care weight-loss interventions (behaviorally based with or without pharmacologic adjuncts) caused harm or adverse events
DESIGN
6498 abstracts reviewed
648 articles reviewed against pre-specified inclusion and exclusion criteria
Included trials were appraised as good, fair, or poor quality
DESIGN
Key Questions 1-3 Randomized controlled clinical trials with
interventions focused on weight loss in adults ≥ 18 years in settings relevant to primary care settings
Key Question 4 Large cohort or case-control studies Large event monitoring Systematic evidence reviews of RCTs (randomized
controlled trials) Did not require 12 months of follow-up
RESULTS
Key Question 1: Screening for Obesity/Overweight
No trials identified in comparing screening vs no screening for adult obesity
RESULTS
Behavioral trial participants: Mean BMI 25 –39 kg/m² 34-70 years-old 60% female <40% non-white
Orlistat trial participants: 66% female <12% non-white
Metformin trial participants: Only one reported ethnicity; 45.3% non-white
Baseline BMI across all trials: 31.9 kg/m² 55% of behavioral trials and 57% orlistat trials had
clinical or subclinical cardiovascular risk factors Metformin trials examined participants with diabetes risk
factors
Patient Characteristics for KQs 2&3
RESULTS
Key Questions 2 & 3: Benefits of Weight-Loss Interventions
58 trials
(identified benefits of weight- loss interventions)
38 trials(13,495
P*)
18 trials(11,256P*)
3 trials(2,652 P*)
BI** Orlistat + BI**
Metformin + BI**
* P = Participants**BI = Behavioral interventions
k1/3 of trials: not included in a weight-loss meta-analysis due to missing information
k k
RESULTS
Key Question 4: Harms of Weight-Loss Interventions
Behavioral Intervention Studies: Total participants: not specified 10 studies used (not specified) Weight loss reduced total or hip bone mineral density in 3
fair-to good-quality trials
Orlistat (+ Behavioral Interventions): Total participants: 12, 174 18 RCTs included from KQs2 &3 5 additional studies not included in KQs 2 &3
Metformin (+ Behavioral Interventions): Total participants : 2,712 4 trials included (3 from KQs 2&3 and 1 additional RCT)
AUTHORS’ CONCLUSION
No direct evidence on benefits and harms of primary care-based obesity screening
Behavioral weight-loss interventions with or without orlistat or metformin yielded clinically meaningful weight loss
COMMENTARY
Strengths Contained analytic framework with 4 key questions Included meta-analysis Included sufficient trials for meta-analysis of behavioral
interventions on weight change data
Limitations: Few studies reported health outcomes Behaviorally based treatments were heterogeneous and specific
elements were not well-described Medication trials were inadequately powered for rare adverse
effects Meta-analysis were not performed on some studies Did not specifically define behavioral interventions Limited good quality trials
COMMENTARY
Long-term weight and health outcomes data were lacking and should be studied
Research should clarify which benefits are derived specifically from weight loss itself or from behavioral mediators, such as physical activity or dietary changes
Weight loss of 6.6 lbs in 12-18 months may be clinically significant in pre-diabetes patients Caution: Orlistat and metformin may cause GI adverse
events Behavioral intervention treatments were safer
A closer look at classification of recommendations and level of evidenceCLASS IIa
Benefit >> RiskAdditional studies with focused objectives needed It is REASONABLE to perform procedure/administer treatment
CLASS IIbBenefit ≥ risk Additional studies with broad objectives
needed; additional registry data would be helpful
Procedure/TreatmentMAY BE CONSIDERED
LEVEL AMultiple populations evaluated
Data derived from MULTIPLE randomized clinical trials or META-ANALYSES
Recommendation in favor of treatment or procedure being useful/effectiveSome conflicting evidence from multiple randomized trials or meta-analyses
Recommendation’s usefulness/efficacy less well establishedGreater conflicting evidence from multiple randomized trials or meta-analyses
LEVEL BLimited populations evaluated
Data derived from a SINGLE randomized trial or NONRANDOMIZED studies
Recommendation in favor of treatment or procedure being useful/effective Some conflicting evidence from a single randomized trial or nonrandomized studies
Recommendation’s usefulness/efficacy less well established Greater conflicting evidence from a single randomized trial or nonrandomized studies
LEVEL CVery limited populations evaluated
Only consensus opinion of experts, case studies, or standard or care
Recommendation in favor of treatment or procedure being useful/effective Only diverging expert opinion, case studies, or standard of care
Recommendation’s usefulness/efficacy less well established Only diverging expert opinion, case studies, or standard of care
Recommendation in favor of treatment or procedure being useful/effective
Some conflicting evidence from multiple randomized trials or meta-analyses
EFFECTIVENESS OF PRIMARY CARE-RELEVANT TREATMENTS FOR OBESITY IN ADULTS: A
SYSTEMATIC EVIDENCE REVIEW FOR THE U.S PREVENTIVE SERVICES
LEBLANC ES, O’CONNOR E, WHITLOCK EP, PATNODE CD, KAPKA T ANN INTERN MED. 2011;155:434-4
FUNDING: AGENCY FOR HEALTHCARE RESEARCH AND QUALITY
Terry SonMercer UniversityOctober 28, 2011
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