Clinical Practice Guideline fr the Management f Obesity in Adults BACKGROUND The prevalence f besity is reaching epidemic prprtins. Obesity is a risk factr fr Type 2 diabetes mellitus, hypertensin, dyslipidemia, crnary artery disease, cerebrvascular disease, and stearthritis. While besity is related t a psitive energy balance, ther factrs cntribute t the increasing prevalence (e.g., envirnmental, cultural, genetic). The United States Preventive Services Task Frce (USPSTF) (2012) 1 recmmends that clinicians screen all adult patients fr besity; individuals with a bdy mass index (BMI) f 30 kg/m 2 r higher shuld be referred t intensive, multicmpnent behaviral interventins t prmte sustained weight lss fr bese adults (Grade B Recmmendatin). Further, the USPSTF (2003) recmmends intensive behaviral dietary cunseling fr adult patients with hyperlipidemia and ther knwn risk factrs fr cardivascular and diet-related chrnic disease. Intensive cunseling can be delivered by primary care clinicians r by referral t ther specialists, such as nutritinists r dietitians (Grade B Recmmendatin). American Heart Assciatin (AHA), American Cllege f Cardilgy (ACC) and The Obesity Sciety (TOS) 2013 Guideline and Recmmendatins 2 Highlights f the AHA/ACC/TOS guideline include: The need fr additinal training as mst primary care prviders (PCPs) are nt trained in besity etilgy, pathgenesis, diagnsis and treatment. The impact f a culture that prmtes supplements and dietary appraches fr quicker, easier weight lss. The need fr authritative, evidence based recmmendatins fr managing weight t imprve member s health. Recmmendatins f the AHA/ACC/TOS Measure height and weight and calculate BMI at annual visits r mre frequently. Use the current cut pints fr verweight (BMI 25.0-29.9 kg/m2) and besity (BMI 30 kg/m2) t identify adults wh may be at elevated risk f cardivascular disease (CVD) and the current cut pints fr besity (BMI 30 kg/m2) t identify adults wh may be at elevated risk f mrtality frm all causes. Advise verweight and bese adults that the greater the BMI, the greater the risk f CVD, type 2 diabetes, and allcause mrtality. Measure waist circumference at annual visits r mre frequently in verweight and bese adults. Advise adults that the greater the waist circumference, the greater the risk f CVD, type 2 diabetes, and all-cause mrtality. Cunsel verweight and bese adults with cardivascular risk factrs (high bld pressure [BP], hyperlipidemia, Clinical Practice Guideline page 1
and hyperglycemia), that lifestyle changes that prduce even mdest, sustained weight lss f 3% 5% prduce clinically meaningful health benefits, and greater weight lsses prduce greater benefits. Sustained weight lss f 3% 5% is likely t result in clinically meaningful reductins in triglycerides, bld glucse, hemglbin A1c, and the risk f develping type 2 diabetes. Greater amunts f weight lss will reduce BP, imprve LDL-C and HDL-C, and reduce the need fr medicatins t cntrl BP, bld glucse and lipids as well as further reduce triglycerides and bld glucse. Prescribe a diet t achieve reduced calrie intake fr bese r verweight individuals wh wuld benefit frm weight lss, as part f a cmprehensive lifestyle interventin. The fllwing methds can be used: Prescribe 1,200 1,500 kcal/d fr wmen and 1,500 1,800 kcal/d fr men (kilcalrie levels are usually adjusted fr the individual s bdy weight); Prescribe a 500-kcal/d r 750-kcal/d energy deficit; r Prescribe ne f the evidence-based diets that restricts certain fd types (such as high-carbhydrate fds, lw-fiber fds, r high-fat fds) in rder t create an energy deficit by reduced fd intake. Prescribe a calrie-restricted diet fr bese and verweight individuals wh wuld benefit frm weight lss, based n the patient s preferences and health status, and preferably refer t a nutritin prfessinal* fr cunseling. A variety f dietary appraches can prduce weight lss in verweight and bese adults. *Nutritin prfessinal: In the studies that frm the evidence base fr this recmmendatin, a registered dietitian usually delivered the dietary guidance; in mst cases, the interventin was delivered in university nutritin departments r in hspital medical care settings where access t nutritin prfessinals was available. Advise verweight and bese individuals wh wuld benefit frm weight lss t participate fr 6 mnths in a cmprehensive lifestyle prgram that assists participants in adhering t a lwer-calrie diet and in increasing physical activity thrugh the use f behaviral strategies. Prescribe n-site, high-intensity (i.e., 14 sessins in 6 mnths) cmprehensive weight lss interventins prvided in individual r grup sessins by a trained interventinist. Electrnically delivered weight lss prgrams (including by telephne) that include persnalized feedback frm a trained interventinist can be prescribed fr weight lss but may result in smaller weight lss than face-t-face interventins. Trained interventinist: In the studies reviewed, trained interventinists included mstly health prfessinals (e.g., registered dietitians, psychlgists, exercise specialists, health cunselrs, r prfessinals in training) wh adhered t frmal prtcls in weight management. In a few cases, lay persns were used as trained interventinists; they received instructin in weight management prtcls (designed by health prfessinals) in prgrams that have been validated in high-quality trials published in peer-reviewed jurnals. Sme cmmercial-based prgrams that prvide a cmprehensive lifestyle interventin can be prescribed as an ptin fr weight lss, prvided there is peer-reviewed published evidence f their safety and efficacy. Use a very-lw-calrie diet (<800 kcal/d) in limited circumstances and when prvided by trained practitiners in a medical care setting where medical mnitring and high-intensity lifestyle interventin can be prvided. Medical supervisin is required due t the rapid rate f weight lss and ptential fr health cmplicatins. There is strng evidence that if a prvider is ging t use a very-lw-calrie diet, it shuld be dne with high levels f mnitring by experienced persnnel; that des nt mean that practitiners shuld prescribe very-lw-calrie diets. Because f cncern thatan ACC/AHA Class I recmmendatin wuld be interpreted t mean that the patients shuld g n a very-lw-calrie diet, it was the cnsensus f the Expert Panel that this maps mre clsely t an ACC/AHA Class IIa recmmendatin. Advise verweight and bese individuals wh have lst weight t participate lng term ( 1 year) in a cmprehensive weight lss maintenance prgram. Clinical Practice Guideline page 2
Fr weight lss maintenance, prescribe face-t-face r telephne-delivered weight lss maintenance prgrams that prvide regular cntact (mnthly r mre frequently) with a trained interventinist wh helps participants engage in high levels f physical activity (i.e., 200 300 min/wk), mnitr bdy weight regularly (i.e., weekly r mre frequently), and cnsume a reduced-calrie diet (needed t maintain lwer bdy weight). Trained interventinist: In the studies reviewed, trained interventinists included mstly health prfessinals (e.g., registered dietitians, psychlgists, exercise specialists, health cunselrs, r prfessinals in training) wh adhered t frmal prtcls in weight management. In a few cases, lay persns were used as trained interventinists; they received instructin in weight management prtcls (designed by health prfessinals) in prgrams that have been validated in high-quality trials published in peer-reviewed jurnals. Advise adults with a BMI 40 kg/m2r BMI 35 kg/m2with besity-related cmrbid cnditins wh are mtivated t lse weight and wh have nt respnded t behaviral treatment with r withut pharmactherapy with sufficient weight lss t achieve targeted health utcme gals that bariatric surgery may be an apprpriate ptin t imprve health and ffer referral t an experienced bariatric surgen fr cnsultatin and evaluatin. There is strng evidence that the benefits f surgery utweigh the risks fr sme patients. These patients can be ffered a referral t discuss surgery as an ptin. This des nt mean that all patients wh meet the criteria shuld have surgery. This decisin-making prcess is quite cmplex and is best perfrmed by experts. The ACC/AHA criterin fr a Class I recmmendatin states that the treatment/prcedure shuld be perfrmed/administered. This recmmendatin as stated des nt meet the criterin that the treatment shuld be perfrmed. Thus, the ACC/AHA classificatin criteria d nt directly map t the NHLBI grade assigned by the Expert Panel. Fr individuals with a BMI <35 kg/m2, there is insufficient evidence t recmmend fr r against underging bariatric surgical prcedures. Advise patients that chice f a specific bariatric surgical prcedure may be affected by patient factrs, including age, severity f besity/bmi, besity-related cmrbid cnditins, ther perative risk factrs, risk f shrt-and lng-term cmplicatins, behaviral and psychscial factrs, and patient tlerance fr risk, as well as prvider factrs (surgen and facility). 3,4 Initial Assessment fr Risk Factrs An individual s bdy mass index (BMI) is bdy weight in kilgrams / height in meters 2. Individuals with a BMI f 25.0 t 29.9 kg/m 2 are cnsidered verweight; a BMI f > 30 kg/m 2 indicates besity. Initial assessment shuld include: Assess degree f besity based n BMI Assess presence f abdminal besity based n waist circumference (see treatment indicatin) Assess presence f underlying diseases and cnditins: Crnary heart disease Type 2 diabetes mellitus Sleep apnea Gyneclgic abnrmalities Ostearthritis Assess presence f cardivascular disease risk factrs: Cigarette smking Impaired fasting glucse Hypertensin Men > 45 years Physical examinatin Assess ther risk factrs such as physical activity level and diet. Labratry tests Fasting bld sugar Triglycerides Urinalysis Stress incntinence Gallstnes and their cmplicatins Other athersclertic diseases (peripheral arterial disease, abdminal artic aneurysm and symptmatic cartid artery disease) High lw-density lipprtein chlesterl (LDL-C) Lw high-density lipprtein chlesterl (HDL-C) Family histry f premature crnary heart disease Wmen > 55 years r pstmenpausal Ttal chlesterl (including LDL-C, HDL-C, HDL-C/TC) Liver functin test Clinical Practice Guideline page 3
Treatment Indicatin, Gals & Mnitring 3,4,5 Treatment fr besity is indicated fr individuals with a BMI > 25 kg/m 2 and < 30 kg/m 2, waist circumference > 40 in (men) r > 35 in (wmen) assciated with tw r mre risk factrs; OR a BMI > 30. Initial visit and assessment at peridic fllw-up visits shuld include: Establishment f healthcare team t include: Attending physician (PCP r specialist) Dietary prfessinal Behaviral health specialist Reduced calrie diet develped in cnjunctin with dietary prfessinal Regular exercise prgram (30 minutes per day, increasing t 60 minutes) develped in cnjunctin with exercise prfessinal Lifestyle interventins and depressin screening in cnjunctin with behaviral health prfessinal Attending physician t mnitr nging prgram cmpliance and weight lss at peridic ffice visits ver 6 mnths. Mnitring f treatment gals shuld take place every six mnths with the fllwing cnsideratins: Shrt-term gal: 10% lss f initial bdy weight in 6 mnths Lng-term gal: Altered and sustained life style behavirs t prvide further weight lss, maintain declined weight, and avid additinal weight gain. Additinal Interventins if Initial Gals Are Nt Met 3,4 Medicatins. The fllwing are apprved fr the treatment f besity: Orlistat: Indicated lng-term, acts n peripheral metablism Sibutramine: Indicated lng term, acts n CNS Benzphetamine: Indicated fr shrt-term use nly, acts n CNS (nrepinephrine-like) Diethylprpin: Indicated fr shrt-term use nly, acts n CNS (nrepinephrine-like) Phendimetrazine: Indicated fr shrt-term use nly, acts n CNS (nrepinephrine-like) Pheentermine: Indicated fr shrt-term use nly, acts n CNS (nrepinephrine-like) Weight lss surgery. Optin fr selected patients with clinically severe besity (BMI > 40 kg/m 2 r BMI > 35 kg/m 2 with cmrbid cnditins) and failure t achieve shrt-term gals after a physician supervised weight lss prgram as described abve. CMS STAR METRIC CMS has nt published a metric fr this cnditin. NCQA HEDIS STANDARD HEDIS 2014-Adult BMI Assessment (ABA) The percentage f members 18 74 years f age wh had an utpatient visit and whse bdy mass index (BMI) was dcumented during the measurement year r the year prir t the measurement year. REFERENCES 1. U.S. Preventive Services Task Frce. (2012). Screening fr besity in adults. Retrieved frm http://www.uspreventiveservicestaskfrce.rg/uspstf/uspsbes.htm 2. Jensen, M.D., Ryan, D.H., Apvian, C.M., Ard, J.D., Cmuzzie, A.G., Dnat, K.A., & et al. (2013). 2013 American Heart Assciatin (AHA), American Cllege f Cardilgy (ACC) and The Obesity Sciety guideline fr the management f verweight and besity in adults. Retrieved frm http://circ.ahajurnals.rg/lkup/di/10.1161/01.cir.0000437739.71477.ee 3. Bray, G.A. (2007). Medical therapy fr besity current status and future hpes. Medical Clinics f Nrth America, 91(6), 1225-1253. Clinical Practice Guideline page 4
4. Lyznicki, J.M., Yung, D.C., Riggs, J.A., Davis, R.M., & Cuncil n Scientific Affairs f the American Medical Assciatin. (2001). Obesity: assessment and management in primary care. American Family Physician, 63(11), 2185-2196. 5. U.S. Preventive Services Task Frce. (2003). Behaviral cunseling in primary care t prmte a healthy diet. Retrieved frm http://www.uspreventiveservicestaskfrce.rg/uspstf/uspsdiet.htm LEGAL DISCLAIMER Clinical Practice Guidelines made available by WellCare are infrmatinal in nature and are nt a substitute fr the prfessinal medical judgment f treating physicians r ther health care practitiners. These guidelines are based n infrmatin available at the time and may nt be updated with the mst current infrmatin available at subsequent times. Individuals shuld cnsult with their physician(s) regarding the apprpriateness f care r treatment ptins t meet their specific needs r medical cnditin. Disclsure f clinical practice guidelines is nt a guarantee f cverage. Members f WellCare health plans shuld cnsult their individual cverage dcuments fr infrmatin regarding cvered benefits. WellCare des nt ffer medical advice r prvide medical care, and therefre cannt guarantee any results r utcmes. WellCare des nt warrant r guarantee, and shall nt be liable fr any deficiencies in the infrmatin cntained herein r fr any inaccuracies r recmmendatins made by independent third parties frm whm any f the infrmatin cntained herein was btained. Nte: The lines f business (LOB) are subject t change withut ntice; cnsult www.wellcare.cm/prviders/cpgs fr list f current LOBs. Easy Chice Health Plan ~ Harmny Health Plan f Illinis, Inc. ~ Missuri Care, Inc. ~ Ohana Health Plan, a plan ffered by WellCare Health Insurance f Arizna, Inc. WellCare Health Insurance f Illinis, Inc. ~ WellCare Health Plans f New Jersey, Inc. ~ WellCare Health Insurance f Arizna, Inc. ~ WellCare f Flrida, Inc. WellCare f Cnnecticut, Inc. WellCare f Gergia, Inc. ~ WellCare f Kentucky, Inc. ~ WellCare f Luisiana, Inc. ~ WellCare f New Yrk, Inc. ~ WellCare f Ohi, Inc. WellCare f Suth Carlina, Inc. ~ WellCare f Texas, Inc. ~ WellCare Prescriptin Insurance, Inc. Windsr Health Plan ~ Windsr Rx Medicare Prescriptin Drug Plan MEDICAL POLICY COMMITTEE HISTORY AND REVISIONS Date Histry and Revisins by the Medical Plicy Cmmittee 8/7/2014 7/31/2014 7/5/2012 12/1/2011 7/2010 Apprved by MPC. Included updated HEDIS metric. Apprved by MPC. Included HEDIS infrmatin and 2013 guidelines and recmmendatins by the AHA, ACC,TOS. Apprved by MPC. Inserted USPSTF recmmendatins (2012 and 2003). New template design apprved by MPC. Apprved by MPC. Clinical Practice Guideline page 5