Obese patients should be referred for counseling but not prescribed weight-loss drugs, panel says

By Deborah Kotz, Globe Staff

An expert panel recommended on Monday that doctors consider giving exercise and diet advice to healthy adults who appear willing to make changes and reiterated old recommendations that doctors screen all adults for obesity. The panel also recommended that obese individuals get referred for behavioral interventions such as diet, exercise, and weight-loss counseling but declined to recommend weight loss drugs such as Orlistat.

That’s despite two promising new medications -- Qnexa and Belviq-- that the US Food and Drug Administration could approve next month if it follows recommendations its advisory committee made in the spring.

“One of the problems with drugs is that the clinical trials just show short-term outcomes,” said Dr. David Grossman, a Seattle pediatrician who led the US Preventive Services Task Force panel that issued the updated recommendations. “Once a person stops taking the drug, we don’t know what happens with long-term weight gain.”

Recommended interventions to tackle obesity consisted of intense group or individual counseling sessions held weekly or monthly with a health professional for several months to a year. But the panel of experts recommended these measures only for those who are obese -- defined as having a body mass index of 30 or above, or 180 pounds or more for a 5-foot, 5-inch person -- not merely overweight.

The panel of experts advised primary care physicians, in a separate set of new recommendations, that they shouldn’t feel the need to provide extensive diet and exercise counseling for healthy adults who don’t have chronic health conditions such as diabetes, hypertension, or heart disease since evidence shows the benefits are “small”.

Obesity experts, however, expressed concern that this was sending the wrong message to doctors. “I worry that there will be a lot of patients who fall through the cracks here and don’t think this will work in the long run,” said Dr. Caroline Apovian, director of the nutrition and weight management center at Boston Medical Center. “You’re not really using prevention.”

Doctors, she added, shouldn’t wait until a patient becomes diabetic before discussing the virtues of cutting back on portions, nor should they wait for overweight patients to become obese before sending them to a dietitian or exercise physiologist for counseling.

Grossman said he hoped primary care physicians understood the subtleties of the new recommendations. “It’s not that we’re saying that exercise and a healthy diet should be left out of the conversation,” he said. “But we’d like doctors to be selective about targeting certain healthy patients such as those who have a high degree of readiness to change due to personal preference or a family history.”

Dr. Lauren Smith, medical director of the Massachusetts Department of Public Health, said she approved of the new recommendations, while pointing out that doctors are only a small part of the solution when it comes to individuals adopting better diet and exercise habits.

“We definitely need individual counseling and motivation,” Smith said, “ but once they leave the office, can they implement the evidence-based advice they just got?” That could be a challenge if their local market doesn’t sell fresh fruits or vegetables or if there’s no safe place for them to walk. “In some communities, it’s really difficult to put those recommendations into practice.”

The state’s three-year-old obesity prevention initiative called “Mass in Motion’’ has targeted a growing list of communities with high obesity rates such as Fitchburg, Gloucester, and Chelsea, providing grants to improve the safety at local parks and increase pedestrian access to sidewalks. New Bedford launched a healthy dining program encouraging restaurants to offer lighter, more nutritious options.