Annals of Internal Medicine is published by the American College of Physicians on the first and third Tuesday of every month. These highlights are not intended to substitute for articles as sources of information. For a copy of an article, call 215-351-2653 or e-mail Angela Collom at firstname.lastname@example.org
Docs Should Screen for Obesity and Direct Obese Patients to Intensive, Multicomponent Behavioral Interventions
In an update to its 2003 recommendation statement on screening for obesity in adults, the United States Preventive Services Task Force recommends screening all adult patients for obesity. Screening includes measurement of height and weight to ascertain BMI, although measuring waist circumference also is an accepted method. Patients with a BMI of 30 or higher should be offered or referred to intensive, multicomponent behavioral interventions such as group or individual weight-loss counseling sessions. The Task Force found that weight-loss outcomes improved when interventions involved at least 12-26 sessions in the first year. Patients with weight-related health issues (high blood pressure, diabetes) saw weight loss and physiologic improvements when behavioral interventions were combined with orlistat or metformin, However, orlistat has been linked to rare, severe liver disease, and metformin has not been approved by the FDA for use as an obesity treatment. Because of safety concerns and insufficient evidence to determine maintenance of improvement after discontinuing drug treatment, the Task Force did not include use of pharmacological agents in the recommendation. In its previous recommendation, the Task Force recommended interventions for overweight adults with a BMI of between 25 and 29.9. But the results of trials included in the evidence review did not allow the Task Force to determine definitively if interventions for individuals who were overweight but not obese would yield the benefits observed in obese individuals.
Task Force Recommendation: Clinicians should selectively provide behavioral counseling in the primary care setting to promote a healthful diet and physical activity rather than incorporating it into the care of all adults in the general population.
Cardiovascular disease is the leading cause of death in the United States. Regardless of their risk status, individuals that follow guidelines for a healthful diet and physical activity can decrease their risk for cardiovascular morbidity and mortality. The United States Preventive Services Task Force reviewed evidence published since its 2002 and 2003 recommendations to determine if primary care-relevant counseling interventions about diet and exercise could change behaviors and improve cardiovascular health among otherwise healthy adults. The Task Force found that medium- to high-intensity behavioral counseling interventions produced small short-term improvements in blood pressure, cholesterol levels, and glucose tolerance. However, available studies rarely involved delivery of the interventions by primary care clinicians. The Task Force recommends that clinicians selectively provide behavioral counseling about diet and activity rather than providing this service to all patients. Issues clinicians should consider include other risk factors for coronary artery disease, a patient’s readiness for change, social support and community resources that support behavioral change, and other health care and preventive service priorities. The Task Force concludes that behavioral counseling may be more effective if delivered in the context of a broader public health intervention that encourages healthy lifestyles (a list of these programs can be found at www.thecommunityguide.org).
Some Boards May be Ready to Implement First of three Key Components as Early as 2014
To obtain initial licensure, physicians must undergo rigorous assessment of clinical knowledge and skills. This process was updated 20 years ago when the Federation of State Medical Boards (FSMB) partnered with the National Board of Medical Examiners to create a three-step United States Medical Licensing Examination -- the test that leads to the initial privilege to practice medicine. To maintain that privilege, physicians have been required since 1971 to complete a certain number of continuing medical education (CME) credit hours with some content-specific course work. However, policymakers and regulators have expressed concern that these requirements are not enough to maintain licensure when the knowledge and skills needed to practice medicine continue to grow exponentially. In 2010, the FSMB’s House of Delegates voted to adopt a framework for maintenance of licensure (MOL) that would address those concerns through three components: reflective self-assessment; assessment of knowledge and skills; and performance in practice. Development of the new MOL framework was guided by several important principles. Of note, MOL should support a physician’s commitment to lifelong learning and facilitate improvement in practice, but without compromising patient care or creating barriers to physician practice (a full list of guiding principles can be found at [insert article URL]. Since implementation of MOL remains in the purview of state medical boards, some may begin to adopt the new framework as early as 2014, and implementation may begin slowly, incorporating one component at a time. “Our goal is to prepare physicians for the gradual transition into the new MOL framework,” said Patrick Alguire, MD, FACP, Senior Vice President of Medical Education at the American College of Physicians and an author of the paper. “We hope this paper sheds some light on the new requirements and the probable timetable for implementation.”