2.  In 2003, the USPSTF recommended that clinicians screen adults for obesity and offer intensive counseling and behavioral interventions to promote weight loss.  However, they concluded that the evidence was insufficient to recommend for or against moderate- or low-intensity counseling plus behavioral interventions to promote sustained weight loss.  They concluded that evidence was insufficient to recommend for or against counseling of any intensity and/or behavioral interventions to promote sustained weight loss in overweight adults.

3.  This was a systematic review to help update these recommendations by looking to answer 4 key questions:  KQ1: Is there direct evidence that PC screening programs for obesity/overweight improve health outcomes or result in short term (12-18 months) or sustained (>18 months) weight loss or improved physiologic measures (i.e., glucose tolerance, BP, HLP)?  KQ2: Do PC-relevant interventions (behavior ± rx) in obese/overweight adults lead to improved health outcomes?  KQ3: Do PC-relevant interventions lead to short-term or sustained weight loss, with or without improved physiologic measures?  KQ4: What are the adverse effects of PC-relevant interventions?

5. KQ 1: Screening → No trials were found comparing screening with no screening for adult obesity. KQ 2and 3: Benefits of weight loss interventions Weight loss  Behavior Interventions: 24% were rated “good” quality trials.  Most trials showed a statistically significant effect on weight loss at 12-18 months (average of 4% of weight loss whereas controls stayed the same).  In 21 trials that could be combined by meta-analysis, patients receiving behavioral interventions lost 3.0kg (6.6 lb) more (95% CI, - 4.0 to -2.0kg) than controls after 12-18 months.  Behavioral interventions lasting longer (24-54 months) continued to show greater weight loss (2-4 kg [4.4-8.8 lb]) compared to controls.  Interventions with more sessions had more weight loss: 12-26 interventions resulted in 4-7kg weight loss (6% of baseline weight) compared to 1.5-5kg (2.8% of baseline weight) in groups with <12 sessions the first year.

6.  Orlistat: only 1 good-quality trial.  Orlistat + behavioral intervention resulted in weight loss of 5-10kg (8% weight) compared to 3-6kg (5% weight) with placebo + behavioral intervention. ▪ All behavioral interventions in these studies were intensive.  In the 12 trials that could be combined by meta-analysis, subjects assigned to orlistat lost 3.0 kg more (95% CI, -3.9 to -2.0kg) than those receiving placebo after 12 months.  Weight loss was maintained with up to 24-36 months of orlistat treatment.  Metformin: only 3 trials analyzed.  Metformin + behavioral intervention was associated with small amount of weight loss (2-4 kg) although the best evidence was limited to patients with prediabetes.

7. Health outcomes  All intervention types did not show an effect on mortality, CVD, hospitalizations or depression (although data was sparse). Diabetes Incidence:  All intervention types reduced diabetes incidence especially those with higher risk.  Behavior interventions that led to weight loss of 4-7kg, reduced incidence by 50% over 2-3 years.  Metformin and orlistat reduced incidence as well (orlistat data may be from confounding variables). Glucose Tolerance  All interventions reduced fasting glucose levels in prediabetic and DM patients at 12-18 months compared to controls.  Behavioral intervention and metformin decreased glucose by 0.30 and 0.31 mmol/L respectively compared to control.  Orlistat decreased glucose 0.672mmol/L possibly because those studies were done in diabetic patients.

8. Lipids analysis:  Behavioral interventions had very small effects on lipids (LDL reduction ≤10 mg/dL) and reporting bias was high because lipids were rarely reported.  Orlistat reduced LDL (11mg/dL) but HDL was also reduced and TG remained the same.  Metformin had no effect. Blood Pressure:  Behavioral intervention and orlistat (+behavioral intervention) reduced SBP/DBP 2mmHg more than control over 12-36 months.  Behavioral intervention reduced the risk for a HTN dx in patients with preHTN (34% and 22% reduced risk at 12 and 18 months, respectively).  Metformin had no effect. Waist circumference  Decreased by 2.7cm more (CI, -4.1 to 1.4cm) in behavioral intervention groups than in control.  Orlist and metformin reduced it by 2.3cm (CI, -3.6 to -0.9cm) and 1.5cm (CI, -2.0 to -1.0cm), compared to placebo.

9. KQ 4:Harms of weight loss interventions  Behavioral interventions:  Weight loss reduced total or hip BMD in 3 fair to good-quality trials. Physical activity had no adverse effects. One study showed no increased risk for eating disorders.  Orlistat  Subjects randomly assigned to receive morlistat were likely to experience adverse effects (mainly GI sx) and withdraw from the trial. Serious adverse events did not occur.  Orlistat also was associated with decreased fat soluble vitamin levels.  Metformin:  Participants randomly assigned to receive metformin were more likely to experience adverse events and withdraw from the trials (due to GI sx). No serious events were reported.

10.  This review found no direct evidence on benefits and harms of PC-based obesity screening.  They found that behavioral weight loss interventions with or without orlistat or metformin resulted in weight loss, decrease in diabetes incidence, glucose and waist circumference.  Health outcomes data was sparse.  Harms of behavioral weight-loss interventions were minimal and data on serious harms from meds were minimal.  Long-term weight and health outcomes data were lacking.