The U.S. Preventive Services Task Force (USPSTF) makes recommendations about the effectiveness of specific preventive care services for patients without obvious related signs or symptoms.

It bases its recommendations on the evidence of both the benefits and harms of the service, and an assessment of the balance. The USPSTF does not consider the costs of providing a service in this assessment.

The USPSTF recognizes that clinical decisions involve more considerations than evidence alone. Clinicians should understand the evidence but individualize decisionmaking to the specific patient or situation. Similarly, the USPSTF notes that policy and coverage decisions involve considerations in addition to the evidence of clinical benefits and harms.

Importance

More than 35% of men and 40% of women in the United States have obesity.^{1, 2} Obesity is associated with health problems such as increased risk for coronary heart disease, type 2 diabetes, various types of cancer, gallstones, and disability.^{1, 3-7} Obesity is also associated with an increased risk for death, particularly among adults younger than age 65 years.¹ The leading causes of death among adults with obesity include ischemic heart disease, type 2 diabetes, respiratory diseases, and cancer (e.g., liver, kidney, breast, endometrial, prostate, and colon cancer).^{1, 3, 8-12}

Benefits of Behavioral Counseling Interventions

The USPSTF found adequate evidence that behavior-based weight loss interventions in adults with obesity can lead to clinically significant improvements in weight status and reduced incidence of type 2 diabetes among adults with obesity and elevated plasma glucose levels. The USPSTF found adequate evidence that behavior-based weight loss maintenance interventions are associated with less weight gain after the cessation of interventions compared with control groups. The magnitude of these benefits is moderate.

Harms of Behavioral Counseling Interventions

The USPSTF found adequate evidence to bound the harms of intensive, multicomponent behavioral interventions (i.e., behavior-based weight loss and weight loss maintenance interventions) in adults with obesity as small to none, based on the absence of reported harms in the evidence and the noninvasive nature of the interventions.

USPSTF Assessment

The USPSTF concludes with moderate certainty that offering or referring adults with obesity to intensive, multicomponent behavioral interventions (i.e., behavior-based weight loss and weight loss maintenance interventions) has a moderate net benefit.

Patient Population Under Consideration

This recommendation applies to adults age 18 years or older. The USPSTF uses the following terms to define categories of increased BMI: “overweight” is a BMI of 25 to 29.9 kg/m² and “obesity” is a BMI of 30 kg/m² or higher. Obesity can be categorized as Class I (BMI of 30.0 to 34.9 kg/m²), Class II (BMI of 35.0 to 39.9 kg/m²), or Class III (BMI of ≥40 kg/m²).

Behavioral Counseling Interventions

Most of the behavioral weight loss interventions (80 studies) considered by the USPSTF lasted for 1 to 2 years, and the majority had 12 or more sessions in the first year.¹ Trials used various delivery methods (group, individual, mixed, technology-based, and print-based). For example, 19 trials provided only virtual contact (i.e., by Web, phone, or print). Interventionists were highly variable across the trials (e.g., 18 trials included interaction with primary care providers).¹ Many of the intensive behavioral interventions considered by the USPSTF were designed to help participants achieve or maintain a 5% or greater weight loss through a combination of dietary changes and increased physical activity. The U.S. Food and Drug Administration considers a weight loss of 5% as clinically important.¹ Most behavioral interventions encouraged self-monitoring of weight and provided tools to support weight loss or weight loss maintenance (e.g., pedometers, food scales, or exercise videos). Similar behavior change techniques and messaging were used across the trials.¹ Few trials had fewer than 12 sessions in the first year.¹ The USPSTF found that the only intervention component significantly related to greater weight loss was any use of group sessions.¹

Trial results were generally not stratified by BMI category. Although some trials included participants who were overweight, the average BMI in the majority of trials was in the obese range (median BMI, >33 kg/m²).¹ Therefore, the USPSTF was unable to examine the differential effects of interventions between participants who were overweight and obese.

Interventions that combined pharmacotherapy with behavioral interventions were associated with greater weight loss and weight loss maintenance over 12 to 18 months compared with interventions that combined behavioral interventions with placebo.¹ However, the participants in the pharmacotherapy trials met highly selective inclusion criteria. Many trials required participants to show compliance with taking medication and meet weight loss goals before enrollment. These trials also had high attrition.¹ Therefore, it is unclear if these trials are applicable to the general U.S. primary care population. In addition, data were lacking about the maintenance of improvement after discontinuation of pharmacotherapy.¹ As a result, the USPSTF encourages clinicians to promote behavioral interventions as the primary effective intervention for weight loss in adults.

Additional Approaches to Prevention

The USPSTF has made recommendations on screening for abnormal blood glucose levels and type 2 diabetes,¹⁴ screening for high blood pressure,¹⁵ statin use in persons at risk for cardiovascular disease,¹⁶ counseling for tobacco smoking cessation,¹⁷ aspirin use in certain persons for prevention of cardiovascular disease,¹⁸ and behavioral counseling interventions to promote a healthful diet and physical activity for cardiovascular disease prevention in adults with and without common risk factors^{19, 20} (Table).

The Community Preventive Services Task Force recommends multicomponent interventions that use technology-supported coaching or counseling to help adults both lose weight and maintain weight loss.²¹

Research Needs and Gaps

Further research is needed to examine the effects of interventions for obesity on longer-term weight and health outcomes (e.g., cardiovascular outcomes), including data on important subgroups (e.g., older adults, racial/ethnic groups, or persons who are overweight). Psychosocial, quality of life, and patient-centered outcomes should continue to be evaluated in future studies. Well-designed pragmatic trials and improved reporting of intervention characteristics may help with evaluation and dissemination of interventions in primary care settings. Future trials are needed to assess recently developed classification systems that characterize obesity severity by evaluating physical, mental, and functional health. Future research is needed on factors (e.g., genetics or unmanaged medical or psychological conditions) that may be barriers to weight loss during behavioral interventions. Trials are needed that examine whether interventions that focus on both weight loss and support of persons living with obesity improve patient-centered outcomes. Comparative effectiveness trials could provide more evidence about the components of effective interventions.

Burden of Disease

During 2013 to 2014, the prevalence of obesity in the United States was greater than 35% among men and 40% among women.² One in 13 Americans has a BMI higher than 40 kg/m² (Class III obesity).²² The age-adjusted prevalence increases to 67.0% among men and 72.8% among women when persons who are overweight are included (according to 2011–2014 data).²³

The prevalence of overweight and obesity varies across racial/ethnic groups. Among women, the age-adjusted prevalence of obesity is higher among non-Hispanic black (57.2%) and Hispanic women (46.9%) than among non-Hispanic white women (38.2%). Among men, obesity prevalence is 38.0% in non-Hispanic black, 37.9% in Hispanic, and 34.7% in non-Hispanic white men.²⁴ Obesity rates among Asian Americans are lower than among other racial/ethnic groups (12.6% and 12.4% in men and women, respectively). However, Asian Americans have higher body fat at a given BMI than other racial/ethnic groups. When using an adjusted cut point of higher than 25 kg/m², obesity prevalence is higher among U.S.-born Asian Americans (43%) than among non-Hispanic whites (36%).²⁵

After adjusting for established risk factors, overweight and obesity have been associated with an increased risk of coronary heart disease, type 2 diabetes, and certain types of cancer. Other diseases associated with obesity include atrial fibrillation/flutter, venous thrombosis, gallstones, gastroesophageal reflux disease, renal disease, and sleep apnea. Potential psychosocial burdens associated with overweight or obesity include weight stigma and eating disorders.^{1, 3-7}

Obesity has been associated with an increased risk of death, particularly among women and adults younger than age 65 years. The leading causes of death among adults with obesity include ischemic heart disease, type 2 diabetes, certain types of cancer (e.g., liver, kidney, breast, endometrial, prostate, and colon cancer), and respiratory diseases.^{1, 8-12}

Scope of Review

The USPSTF commissioned a systematic evidence review to update its 2012 recommendation on screening for obesity in adults.²⁶ The USPSTF reviewed evidence on interventions (behavioral interventions and pharmacotherapy) for weight loss or weight loss maintenance that can be provided in or referred from a primary care setting. Surgical weight loss interventions and nonsurgical weight loss devices (e.g., gastric balloons) are considered to be outside the scope of the primary care setting.

Effectiveness of Behavioral Counseling Interventions

The USPSTF reviewed the evidence on four types of interventions: behavior-based weight loss (80 trials), behavior-based weight loss maintenance (9 trials), pharmacotherapy-based weight loss (32 trials), and pharmacotherapy-based weight loss maintenance (3 trials). In the weight loss maintenance trials, patient randomization occurred after prior weight loss.¹

Behavioral Counseling Interventions

The USPSTF identified 89 behavior-based weight loss and weight loss maintenance trials, of which 26 were good quality and 63 were fair quality. Eighty trials focused on behavior-based weight loss interventions.¹ The majority of behavior-based weight loss intervention trials (47 trials) were conducted in the United States; other study sites included Europe (15 trials), the United Kingdom (11 trials), Japan (3 trials), Australia (2 trials), and Canada (2 trials). In more than half of the trials (40 trials), participants came from an unselected population of adults who were overweight or had obesity. In the remaining trials, enrolled participants had elevated clinical or subclinical risk of cardiovascular disease or cancer.¹ Trial sample sizes ranged from 30 to 2,161. The mean baseline BMI ranged from 25 to 39.2 kg/m² (median, 33.4 kg/m²) and the mean age ranged from 22 to 66 years (median, 50.3 years). Fourteen trials were limited to female participants, and four trials were restricted to men.¹ Eleven trials focused on specific racial/ethnic groups (e.g., African American, Asian and South Asian, American Indian, or Hispanic race/ethnicity). Socioeconomic status was not well reported in trials; however, when described, most participants were of medium to high socioeconomic status. Most trials did not stratify results by BMI, age, race/ethnicity, or health status.¹

Nine trials focused on behavior-based weight loss maintenance.¹ Study sites were in the United States, United Kingdom, Finland, and Australia. In most trials (8 trials), participants came from an unselected population of adults who were overweight or had obesity. One trial enrolled participants with cardiovascular risk factors.¹ Trial sample sizes ranged from 92 to 1,032. Participants were required to meet weight loss goals before enrollment. The mean BMI at enrollment ranged from 28.4 to 41.7 kg/m². The mean age ranged from 46.4 to 61.8 years (median, 49.2 years).¹ One trial was limited to women and one trial was limited to men. The majority of trials did not report information regarding race/ethnicity or socioeconomic status. When reported, participants were mostly white and of medium to high socioeconomic status.¹

Behavior-Based Weight Loss and Weight Maintenance Interventions

Health outcomes. Few health outcomes were identified in the behavior-based weight loss and weight loss maintenance trials (20 trials; n=9,910). There were no significant differences in mortality between intervention and control groups (4 trials; n=4,442). There were also no significant differences in cardiovascular events between intervention and control groups (2 trials; n=2,666).¹ Trials that examined health-related quality of life (17 trials; n=7,120) mostly demonstrated a lack of statistically significant differences between intervention and control groups.

Intermediate outcomes. Intermediate outcomes (e.g., prevalence of high blood pressure or metabolic syndrome, use of cardiovascular disease medications, estimated 10-year risk of cardiovascular disease) were seldom reported. Effects on cardiovascular disease risk, metabolic syndrome, high blood pressure or hyperlipidemia diagnoses, and medication use were mixed.

Thirteen behavior-based weight loss trials (n=4,095) evaluated incident type 2 diabetes in intervention vs. control groups. Twelve of the 13 trials were among participants with impaired fasting glucose or increased risk for type 2 diabetes (i.e., persons with a family history, history of gestational diabetes, or metabolic syndrome). In the good-quality Diabetes Prevention Program trial (n=1,295), the estimated cumulative incidence of type 2 diabetes at 3 years was 14.4% vs. 28.9% in the intervention vs. placebo groups, respectively, and the number needed to treat to prevent 1 case of diabetes was 6.9. The good-quality Finnish Diabetes Prevention Study (n=523) demonstrated that participants in the intervention group were significantly less likely to develop type 2 diabetes than those in the control group after 9 years (40.0% vs. 54.5%, respectively; hazard ratio, 0.4 [95% confidence interval (CI), 0.3 to 0.7]). In the remaining trials, the differences between the intervention and control groups were not statistically significant. However, these trials were smaller and shorter than the larger trials. Pooling the trials (9 studies; n=3,140) showed a significant 33% reduction in the risk of developing type 2 diabetes over 1 to 9 years (pooled risk ratio, 0.67 [95% CI, 0.51 to 0.89]; I²=49.2%).^{1, 27-29}

Weight outcomes. Participants in behavioral-based weight loss intervention groups demonstrated greater weight loss and decreased waist circumference compared with those in control groups at 24 months of followup. At 12 to 18 months, pooled results showed greater weight loss among intervention participants (−2.39 kg [−5.3 lb] [95% CI, −2.86 to −1.93]; 67 trials; n=22,065; I²=90.0%).¹ The mean absolute change in weight ranged from −0.5 kg (−1.1 lb) to −9.3 kg (−20.5 lb) among intervention groups and from 1.4 kg (3.1 lb) to −5.6 (−12.3 lb) among control groups. At 12 to 18 months, intervention participants were more likely to lose 5% of their initial weight compared with control participants (risk ratio, 1.94 [95% CI, 1.70 to 2.22]; 38 trials; n=12,231; I²=67.2%; number needed to treat=8).¹ Participants in weight loss maintenance interventions had less weight gain compared with participants in control groups (pooled mean difference in weight change, −1.59 kg [−3.5 lb] [95% CI, −2.38 to −0.79]; 8 studies; n=1,408; I²=26.8%).¹

Behavioral Counseling and Pharmacotherapy Interventions

Pharmacotherapy trials evaluated liraglutide (3 trials), lorcaserin (2 trials), naltrexone and bupropion (3 trials), orlistat (13 trials), and phentermine-topiramate (2 trials).¹ All trials were fair quality. The trials were conducted in the United States, Europe, Australia, New Zealand, and other regions. Participant characteristics were similar to those in the behavioral intervention trials. Many trials required participants to demonstrate medication compliance and/or meet weight loss goals prior to enrollment. The more narrowly defined inclusion criteria of these trials resulted in more selective populations enrolled as study participants.¹ Meta-analyses could not be conducted because of the few number of trials for each drug or variability in outcome reporting. The review of pharmacotherapy-based trials was limited to dosages approved by the U.S. Food and Drug Administration. Within trials, study groups received the same behavioral interventions. The rate of trial completion in the medication and placebo groups ranged from 10% to 93% (most were 50% to 70%).¹

Pharmacotherapy-Based Weight Loss and Weight Maintenance Interventions

Health outcomes. Ten trials examined quality of life (n=13,145).¹ Many trials showed improvement in obesity-specific quality of life measures among participants receiving pharmacotherapy compared with placebo. However, these outcomes are difficult to interpret because of high study dropout rates (≥35% in half of the included trials), the small differences between study groups, and the unclear clinical significance of improved quality of life scores.¹ Trials that reported cardiovascular events found few events in any group (2 trials; n=6,210). Pharmacotherapy-based weight loss maintenance trials did not report any health outcomes.¹

Intermediate outcomes. Limited data from four trials examined weight loss medication and incident diabetes (n=9,763) and found a reduced risk of diabetes. However, these trials were limited by high dropout rates.^{1, 13} Other intermediate outcomes (use of lipid-lowering and antihypertensive medications, prevalence of metabolic syndrome, and 10-year risk of cardiovascular disease) were sparsely reported and had mixed findings.¹

Weight outcomes. At 12 to 18 months, participants in pharmacotherapy-based weight loss trials (32 trials) had more weight loss compared with placebo groups (mean/least squares mean difference in weight change, −1.0 kg [−2.2 lb] to −5.8 kg [−12.8 lb]).^{1, 13} Participants also experienced a greater decrease in waist circumference and a greater likelihood of losing 5% of their initial weight compared with placebo groups. Three pharmacotherapy-based weight loss maintenance trials showed that participants receiving the intervention had better weight loss maintenance compared with placebo groups over 12 to 36 months (mean difference, −0.6 to −3.5 kg).¹

Potential Harms of Behavioral Counseling Interventions

Behavior-Based Weight Loss and Weight Maintenance Interventions

Thirty trials (n=12,824) examined the harms of behavior-based weight loss and weight maintenance interventions. Fifteen trials were good quality and 15 trials were fair quality. Intervention harms were sparsely reported. Overall, the trials showed no serious harms, and most trials observed no difference in the rate of adverse events between intervention and control groups. Three trials demonstrated mixed results for musculoskeletal problems.

Pharmacotherapy-Based Weight Loss and Weight Maintenance Interventions

Thirty-three trials and two observational studies (n=239,428), all of fair quality, assessed the harms of pharmacotherapy-based weight loss and weight maintenance interventions. Serious adverse events were not common and were similar between groups.¹ Adverse event rates were high in both intervention and placebo groups by 12 months, with 80% to 96% of participants experiencing an adverse event in the medication group compared with 63% to 94% in the placebo group. The higher rate of adverse events in the medication groups resulted in higher dropout rates than in the placebo groups.¹

Estimate of Magnitude of Net Benefit

The USPSTF found adequate evidence 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; these interventions are of moderate benefit. The USPSTF found adequate evidence that behavior-based weight loss maintenance interventions are of moderate benefit. The USPSTF found adequate evidence that the harms of intensive, multicomponent behavioral interventions (including weight loss maintenance interventions) in adults with obesity are small to none.

Therefore, the USPSTF concludes with moderate certainty that offering or referring adults with obesity to intensive behavioral interventions or behavior-based weight loss maintenance interventions has a moderate net benefit.

This recommendation updates the 2012 USPSTF recommendation statement on screening for obesity in adults (B recommendation).²⁶

The Canadian Task Force on Preventive Health Care recommends screening for obesity with BMI in adults at primary care visits.³⁰ The Academy of Nutrition and Dietetics, American College of Cardiology, American Heart Association, and the Obesity Society recommend screening for obesity with BMI and waist circumference in adults.^{31, 32} The American Association of Clinical Endocrinologists, American College of Endocrinology, and the National Institute for Health and Care Excellence recommend screening for obesity with BMI and using waist circumference as a supplement in adults with a BMI higher than 35 kg/m².^{33, 34} The American Academy of Family Physicians recommends screening for obesity in all adults and offering or referring patients with a BMI of 30 kg/m² or higher to intensive, multicomponent behavioral interventions.³⁵

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2. Ogden CL, Carroll MD, Fryar CD, Flegal KM. Prevalence of obesity among adults and youth: United States, 2011-2014. NCHS Data Brief. 2015(219):1-8.
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^a BMI calculated as weight in kilograms divided by the square of height in meters.
^b The USPSTF recommends screening for abnormal blood glucose levels as part of cardiovascular risk assessment in adults ages 40 to 70 years who are overweight or have obesity. Patients with certain risk factors (family history of diabetes, personal history of gestational diabetes or polycystic ovarian syndrome, or being a member of certain racial/ethnic groups [African Americans, American Indians or Alaskan Natives, Asian Americans, Hispanics or Latinos, or Native Hawaiians or Pacific Islanders]) may also be at increased risk of diabetes at a younger age or at a lower BMI and should be considered for screening.

Abbreviation: BMI=body mass index.