The Guide to Clinical Preventive Services 2008 - part 7 ppt

Clinical Considerationsn Regular physical activity helps prevent cardiovascular disease, hypertension, type 2 diabetes, obesity, and osteoporosis.. Benefitsincrease with increasing level

Screening for Obesity in Adults

other diseases independent of obesity Cliniciansmay use the waist circumference as a measure ofcentral adiposity Men with waist circumferencesgreater than 102 cm (> 40 inches) and women withwaist circumferences greater than 88 cm (> 35inches) are at increased risk for cardiovasculardisease The waist circumference thresholds are notreliable for patients with a BMI greater than 35

n Expert committees have issued guidelines definingoverweight and obesity based on BMI Persons with

a BMI between 25 and 29.9 are overweight andthose with a BMI of 30 and above are obese Thereare 3 classes of obesity: class I (BMI 30-34.9), class

II (BMI 35-39.9), and class III (BMI 40 andabove) BMI is calculated either as weight inpounds divided by height in inches squared

multiplied by 703, or as weight in kilogramsdivided by height in meters squared The NationalInstitutes of Health (NIH) provides a BMI

calculator at www.nhlbisupport.com/bmi/ and atable at www.nhlbi.nih.gov/guidelines/obesity/bmi_tbl.htm

n The most effective interventions combine nutritioneducation and diet and exercise counseling withbehavioral strategies to help patients acquire theskills and supports needed to change eating patternsand to become physically active The 5-A

framework (Assess, Advise, Agree, Assist, andArrange) has been used in behavioral counselinginterventions such as smoking cessation and may be

Screening for Obesity in Adults

for weight loss Initial interventions paired withmaintenance interventions help ensure that weightloss will be sustained over time

n It is advisable to refer obese patients to programsthat offer intensive counseling and behavioralinterventions for optimal weight loss The USPSTFdefined intensity of counseling by the frequency ofthe intervention A high-intensity intervention ismore than 1 person-to-person (individual or group)session per month for at least the first 3 months ofthe intervention A medium-intensity intervention

is a monthly intervention, and anything less

frequent is a low-intensity intervention There arelimited data on the best place for these

interventions to occur and on the composition ofthe multidisciplinary team that should deliver high-intensity interventions

n The USPSTF concluded that the evidence on theeffectiveness of interventions with obese people maynot be generalizable to adults who are overweightbut not obese The evidence for the effectiveness ofinterventions for weight loss among overweightadults, compared with obese adults, is limited

n Orlistat and sibutramine, approved for weight loss

by the Food and Drug Administration, can producemodest weight loss (2.6-4.8 kg) that can be

sustained for at least 2 years if the medication iscontinued The adverse effects of orlistat includefecal urgency, oily spotting, and flatulence; theadverse effects of sibutramine include an increase in

Screening for Obesity in Adults

blood pressure and heart rate There are no data onthe long-term (longer than 2 years) benefits oradverse effects of these drugs Experts recommendthat pharmacological treatment of obesity be usedonly as part of a program that also includes lifestylemodification interventions, such as intensive dietand/or exercise counseling and behavioral

interventions

n There is fair to good evidence to suggest thatsurgical interventions such as gastric bypass, verticalbanded gastroplasty, and adjustable gastric bandingcan produce substantial weight loss (28 to > 40 kg)

in patients with class III obesity Clinical guidelinesdeveloped by the National Heart, Lung, and BloodInstitute (NHLBI) Expert Panel on the

identification, evaluation, and treatment of

overweight and obesity in adults recommend thatthese procedures be reserved for patients with classIII obesity and for patients with class II obesity whohave at least 1 other obesity-related illness Thepostoperative mortality rate for these procedures is0.2 percent Other complications include woundinfection, re-operation, vitamin deficiency, diarrhea,and hemorrhage Re-operation may be necessary in

up to 25 percent of patients Patients should receive

a psychological evaluation prior to undergoing theseprocedures The long-term health effects of surgeryfor obesity are not well characterized

n The data supporting the effectiveness of

interventions to promote weight loss are derived

Screening for Obesity in Adults

mostly from women, especially white women Theeffectiveness of the interventions is less wellestablished in other populations, including theelderly The USPSTF believes that, although thedata are limited, these interventions may be usedwith obese men, physiologically mature olderadolescents, and diverse populations, taking intoaccount cultural and other individual factors

This USPSTF recommendation was first published in:

Ann Intern Med 2003;139:930-932.

Clinical Considerations

n Regular physical activity helps prevent

cardiovascular disease, hypertension, type 2

diabetes, obesity, and osteoporosis It may alsodecrease all-cause morbidity and lengthen life-span.1

n Benefits of physical activity are seen at even modestlevels of activity, such as walking or bicycling 30minutes per day on most days of the week Benefitsincrease with increasing levels of activity.2

n Whether routine counseling and follow-up byprimary care physicians results in increased physicalactivity among their adult patients is unclear.Existing studies limit the conclusions that can bedrawn about efficacy, effectiveness, and feasibility ofprimary care physical activity counseling Moststudies have tested brief, minimal, and low-intensityprimary care interventions, such as 3 to 5 minutecounseling sessions in the context of a routineclinical visit

Behavioral Counseling in Primary Care

to Promote Physical Activity

Summary of Recommendation

The U.S Preventive Services Task Force

(USPSTF) concludes that the evidence is

insufficient to recommend for or against behavioralcounseling in primary care settings to promote

physical activity Grade: I Statement

Physical Activity

n Multi-component interventions combining provideradvice with behavioral interventions to facilitate andreinforce healthy levels of physical activity appear themost promising Such interventions often includepatient goal setting, written exercise prescriptions,individually tailored physical activity regimens, andmailed or telephone follow-up assistance provided byspecially trained staff Linking primary care patients

to community-based physical activity and fitnessprograms may enhance the effectiveness of primarycare clinician counseling.3

n Potential harms of physical activity counseling havenot been well defined or studied They may includemuscle and fall-related injuries or cardiovascularevents.4It is unclear whether more extensive patientscreening, certain types of physical activity (e.g.,moderate vs vigorous exercise), more gradual

increases in exercise, or more intensive counselingand follow-up monitoring will decrease the likelihood

of injuries related to physical activity Existing studiesprovide insufficient evidence regarding the potentialharms of various activity protocols, such as moderatecompared with vigorous exercise

References

1 U.S Department of Health and Human Services Healthy

People 2010, conference edition Washington DC: U.S.

Department of Health and Human Services; 2000.Available at: http://www.health.gov/healthypeople/Document/HTML/Volume2/22Physical.htm AccessedMay 30, 2002

Physical Activity

2 U.S Department of Health and Human Services

Physical Activity and Health: A Report of the Surgeon General Atlanta, GA: U.S Department of Health and

Human Services, Centers for Disease Control andPrevention National Center for Chronic DiseasePrevention and Health Promotion; 1996 Available at:http://www.cdc.gov/nccdphp/sgr/pdf/sgrfull.pdf.Accessed May 30, 2002

3 Task Force on Community Preventive Services

Recommendations to increase physical activity in

communities Am J Prev Med 2002;22(4S):67-72.

Available at: http://www.thecommunityguide.org/.Accessed June 7, 2002

4 The Writing Group for the Activity Counseling TrialResearch Group Effects of physical activity

counseling in primary care: The activity counseling trial:

a randomized controlled trial JAMA

2001;286:677-687

This USPSTF recommendation was first published in:

Ann Intern Med 2002;137:205-207.

Clinical Considerations

n Subclinical thyroid dysfunction is defined as anabnormal biochemical measurement of thyroidhormones without any specific clinical signs orsymptoms of thyroid disease and no history ofthyroid dysfunction or therapy This includesindividuals who have mildly elevated TSH andnormal thyroxine (T4) and triiodothyronine (T3)levels (subclinical hypothyroidism), or low TSH andnormal T4 and T3 levels (subclinical

hyperthyroidism) Individuals with symptoms ofthyroid dysfunction, or those with a history ofthyroid disease or treatment, are excluded from thisdefinition and are not the subject of these

recommendations

n When used to confirm suspected thyroid disease inpatients referred to a specialty endocrine clinic,TSH has a high sensitivity (98%) and specificity(92%) When used for screening primary carepopulations, the positive predictive value (PPV) ofTSH in detecting thyroid disease is low; further, theinterpretation of a positive test result is often

Screening for Thyroid Disease

Summary of Recommendation

The U.S Preventive Services Task Force

(USPSTF) concludes the evidence is insufficient torecommend for or against routine screening for

thyroid disease in adults Grade: I Statement.

Screening for Thyroid Disease

complicated by an underlying illness or by frailty ofthe individual In general, values for serum TSHbelow 0.1 mU/L are considered low and valuesabove 6.5 mU/L are considered elevated

n Clinicians should be aware of subtle signs of thyroiddysfunction, particularly among those at high risk.People at higher risk for thyroid dysfunctioninclude the elderly, post-partum women, those withhigh levels of radiation exposure (>20 mGy), andpatients with Down syndrome Evaluating forsymptoms of hypothyroidism is difficult in patientswith Down syndrome because some symptoms andsigns (e.g., slow speech, thick tongue, and slowmentation) are typical findings in both conditions

n Subclinical hyperthyroidism has been associatedwith atrial fibrillation, dementia, and, less clearly,with osteoporosis However, progression fromsubclinical to clinical disease in patients without ahistory of thyroid disease is not clearly established

n Subclinical hypothyroidism is associated with poorobstetric outcomes and poor cognitive development

in children Evidence for dyslipidemia,

atherosclerosis, and decreased quality of life inadults with subclinical hypothyroidism in thegeneral population is inconsistent and less

convincing

This USPSTF recommendation was first published in:

Ann Intern Med 2004;125-127.

Screening for Type 2 Diabetes Mellitus

in Adults

NOTE: The USPSTF revised its recommendation

on this topic during publication of The Guide to

Clinical Preventive Services 2008 For the most

recent recommendation, please visit our Web site

at http://www.preventiveservices.ahrq.gov or theUSPSTF’s Electronic Preventive Services Selector(ePSS) at http://epss.ahrq.gov You can search theePSS for recommendations by patient age, sex, andpregnancy status, and you can download therecommendations as well as receive automaticupdates to your PDA

Clinical Considerations

n Although exercise has not been shown to preventlow back pain, regular physical activity has otherproven health benefits, including prevention ofcardiovascular disease, hypertension, type 2diabetes, obesity, and osteoporosis

n Neither lumbar supports nor back belts appear to

be effective in reducing the incidence of low backpain

n Worksite interventions, including educationalinterventions, have some short-term benefit inreducing the incidence of low back pain However,their applicability to the primary care setting isunknown

Musculoskeletal Conditions

Primary Care Interventions to Prevent Low Back Pain in Adults

Summary of Recommendation

The U.S Preventive Services Task Force

(USPSTF) concludes that the evidence is

insufficient to recommend for or against theroutine use of interventions to prevent low back

pain in adults in primary care settings Grade: I

Statement.

Low Back Pain in Adults

n Back schools may prevent further back injury forindividuals with recurrent or chronic low back pain,but their long-term effectiveness has not been wellstudied

This USPSTF recommendation was first published by:Agency for Healthcare Research and Quality, Rockville, MD.February 2004 http://www.preventiveservices.ahrq.gov

Clinical Considerations

n Modeling analysis suggests that the absolutebenefits of screening for osteoporosis amongwomen aged 60-64 who are at increased risk forosteoporosis and fracture are comparable to those

of routine screening in older women The exactrisk factors that should trigger screening in thisage group are difficult to specify based onevidence Lower body weight (weight < 70 kg ) is

Screening for Osteoporosis in

Postmenopausal Women

Summary of Recommendations

The U.S Preventive Services Task Force(USPSTF) recommends that women aged 65 andolder be screened routinely for osteoporosis TheUSPSTF recommends that routine screeningbegin at age 60 for women at increased risk forosteoporotic fractures (see Clinical

Considerations for discussion of women at

increased risk) Grade: B Recommendation.

The USPSTF makes no recommendation for

or against routine osteoporosis screening inpostmenopausal women who are younger than 60

or in women aged 60-64 who are not at increased

risk for osteoporotic fractures Grade: C

Recommendation.

Screening for Osteoporosis in Postmenopausal Women

the single best predictor of low bone mineraldensity.1,2

Low weight and no current use ofestrogen therapy are incorporated with age intothe 3-item Osteoporosis Risk Assessment

Instrument (ORAI).1,2 There is less evidence tosupport the use of other individual risk factors (forexample, smoking, weight loss, family history,decreased physical activity, alcohol or caffeine use,

or low calcium and vitamin D intake) as a basisfor identifying high-risk women younger than 65

At any given age, African-American women onaverage have higher bone mineral density (BMD)than white women and are thus less likely tobenefit from screening

n Among different bone measurement tests

performed at various anatomical sites, bonedensity measured at the femoral neck by dual-energy x-ray absorptiometry (DXA) is the bestpredictor of hip fracture and is comparable toforearm measurements for predicting fractures atother sites Other technologies for measuringperipheral sites include quantitative

ultrasonography (QUS), radiographic

absorptiometry, single energy x-ray absorptiometry,peripheral dual-energy x-ray absorptiometry, andperipheral quantitative computed tomography.Recent data suggest that peripheral bone density