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Adult vaccination record
The Centers for Disease Control and Prevention offer a handy adult immunization record that can be easily appended to medical charts. Click here to access a copy of the form.
The Centers for Disease Control and Prevention offer a handy adult immunization record that can be easily appended to medical charts. Click here to access a copy of the form.
The Centers for Disease Control and Prevention offer a handy adult immunization record that can be easily appended to medical charts. Click here to access a copy of the form.
Vaccine storage and handling toolkit
The Vaccine Storage and Handling Toolkit is based on the recommendations of the Advisory Committee on Immunization Practices (ACIP), the manufacturer's product information and studies from the National Institute for Scientific Technology (NIST). Click here to view or print a free copy of the Toolkit.
The Vaccine Storage and Handling Toolkit is based on the recommendations of the Advisory Committee on Immunization Practices (ACIP), the manufacturer's product information and studies from the National Institute for Scientific Technology (NIST). Click here to view or print a free copy of the Toolkit.
The Vaccine Storage and Handling Toolkit is based on the recommendations of the Advisory Committee on Immunization Practices (ACIP), the manufacturer's product information and studies from the National Institute for Scientific Technology (NIST). Click here to view or print a free copy of the Toolkit.
AHRQ’s Web M&M explores complexities in monitoring fetal health
Follow a case and the associated discussion, to learn the latest evidence on fetal heart rate monitoring and the appropriate approaches to monitoring in labor and delivery units via an exercise sponsored by the Agency for Healthcare Research and Quality.
Click here to learn more at the AHRQ Web M&M site.
Follow a case and the associated discussion, to learn the latest evidence on fetal heart rate monitoring and the appropriate approaches to monitoring in labor and delivery units via an exercise sponsored by the Agency for Healthcare Research and Quality.
Click here to learn more at the AHRQ Web M&M site.
Follow a case and the associated discussion, to learn the latest evidence on fetal heart rate monitoring and the appropriate approaches to monitoring in labor and delivery units via an exercise sponsored by the Agency for Healthcare Research and Quality.
Click here to learn more at the AHRQ Web M&M site.
Medication reconciliation toolkit
During transitions in care, unintentional medication discrepancies commonly occur and can threaten patient safety. To improve medication reconciliation, and in response to Joint Commission requirements, most hospitals have developed medication reconciliation processes.
The successes of such programs have been varied, but there is now collective experience about effective approaches to medication reconciliation.
MARQUIS identifies best practices and offers a framework for assembling a team and adaptable implementation strategy.
To download a copy of the implementation strategy developed by the Society of Hospital Medicine, click here.
During transitions in care, unintentional medication discrepancies commonly occur and can threaten patient safety. To improve medication reconciliation, and in response to Joint Commission requirements, most hospitals have developed medication reconciliation processes.
The successes of such programs have been varied, but there is now collective experience about effective approaches to medication reconciliation.
MARQUIS identifies best practices and offers a framework for assembling a team and adaptable implementation strategy.
To download a copy of the implementation strategy developed by the Society of Hospital Medicine, click here.
During transitions in care, unintentional medication discrepancies commonly occur and can threaten patient safety. To improve medication reconciliation, and in response to Joint Commission requirements, most hospitals have developed medication reconciliation processes.
The successes of such programs have been varied, but there is now collective experience about effective approaches to medication reconciliation.
MARQUIS identifies best practices and offers a framework for assembling a team and adaptable implementation strategy.
To download a copy of the implementation strategy developed by the Society of Hospital Medicine, click here.
Guideline: Diagnosis and treatment of interstitial cystitis/bladder pain syndrome
Updates have been issued to guidelines on diagnosing and treating interstitial cystitis and bladder pain by the American Urological Association.
The basic assessment should include a careful history, physical examination, and laboratory examination to rule in symptoms that characterize interstitial cystitis/bladder pain syndrome (and rule out other disorders). Baseline voiding symptoms and pain levels should be obtained in order to measure subsequent treatment effects.
Overall management should initially focus on conservative therapies including patient education, behavior modification, and stress management. Treatment, including pain management, is determined by symptom severity, clinician judgment, and patient preferences.
Second-line treatments include manual physical therapy techniques, oral medications (amitriptyline, cimetidine, hydroxyzine, or pentosan polysulfate), and intravesical treatments (dimethyl sulfoxide, heparin, or lidocaine). Third-line treatments are cystoscopy under anesthesia with short-duration, low-pressure hydrodistension, fulguration, and injection of triamcinolone, the guidelines state.
Find the full guideline sat the Agency for Healthcare Research and Quality website.
Updates have been issued to guidelines on diagnosing and treating interstitial cystitis and bladder pain by the American Urological Association.
The basic assessment should include a careful history, physical examination, and laboratory examination to rule in symptoms that characterize interstitial cystitis/bladder pain syndrome (and rule out other disorders). Baseline voiding symptoms and pain levels should be obtained in order to measure subsequent treatment effects.
Overall management should initially focus on conservative therapies including patient education, behavior modification, and stress management. Treatment, including pain management, is determined by symptom severity, clinician judgment, and patient preferences.
Second-line treatments include manual physical therapy techniques, oral medications (amitriptyline, cimetidine, hydroxyzine, or pentosan polysulfate), and intravesical treatments (dimethyl sulfoxide, heparin, or lidocaine). Third-line treatments are cystoscopy under anesthesia with short-duration, low-pressure hydrodistension, fulguration, and injection of triamcinolone, the guidelines state.
Find the full guideline sat the Agency for Healthcare Research and Quality website.
Updates have been issued to guidelines on diagnosing and treating interstitial cystitis and bladder pain by the American Urological Association.
The basic assessment should include a careful history, physical examination, and laboratory examination to rule in symptoms that characterize interstitial cystitis/bladder pain syndrome (and rule out other disorders). Baseline voiding symptoms and pain levels should be obtained in order to measure subsequent treatment effects.
Overall management should initially focus on conservative therapies including patient education, behavior modification, and stress management. Treatment, including pain management, is determined by symptom severity, clinician judgment, and patient preferences.
Second-line treatments include manual physical therapy techniques, oral medications (amitriptyline, cimetidine, hydroxyzine, or pentosan polysulfate), and intravesical treatments (dimethyl sulfoxide, heparin, or lidocaine). Third-line treatments are cystoscopy under anesthesia with short-duration, low-pressure hydrodistension, fulguration, and injection of triamcinolone, the guidelines state.
Find the full guideline sat the Agency for Healthcare Research and Quality website.
Guideline: Screening, assessment, and care of anxiety and depression in adults with cancer
A Canadian guideline on screening, assessment, and care of anxiety and depressive symptoms in adults with cancer has been adapted for the United States by the American Society of Clinical Oncology.
It is recommended that all patients with cancer be evaluated for symptoms of depression and anxiety at periodic times across the trajectory of care. Assessment should be performed using validated, published measures and procedures. Depending on levels of symptoms and supplementary information, differing treatment pathways are recommended. Failure to identify and treat anxiety and depression increases the risk for poor quality of life and potential disease-related morbidity and mortality, according to ASCO.
The full guideline can be found on the Agency for Healthcare Research and Quality website.
A Canadian guideline on screening, assessment, and care of anxiety and depressive symptoms in adults with cancer has been adapted for the United States by the American Society of Clinical Oncology.
It is recommended that all patients with cancer be evaluated for symptoms of depression and anxiety at periodic times across the trajectory of care. Assessment should be performed using validated, published measures and procedures. Depending on levels of symptoms and supplementary information, differing treatment pathways are recommended. Failure to identify and treat anxiety and depression increases the risk for poor quality of life and potential disease-related morbidity and mortality, according to ASCO.
The full guideline can be found on the Agency for Healthcare Research and Quality website.
A Canadian guideline on screening, assessment, and care of anxiety and depressive symptoms in adults with cancer has been adapted for the United States by the American Society of Clinical Oncology.
It is recommended that all patients with cancer be evaluated for symptoms of depression and anxiety at periodic times across the trajectory of care. Assessment should be performed using validated, published measures and procedures. Depending on levels of symptoms and supplementary information, differing treatment pathways are recommended. Failure to identify and treat anxiety and depression increases the risk for poor quality of life and potential disease-related morbidity and mortality, according to ASCO.
The full guideline can be found on the Agency for Healthcare Research and Quality website.
Guideline: Therapy for women with HER2-negative or unknown advanced breast cancer
A new guideline on identifying optimal chemotherapy and targeted therapy for women with human epidermal growth factor 2–negative or unknown advanced breast cancer has been released by the American Society of Clinical Oncology.
Endocrine therapy is preferable to chemotherapy as first-line treatment for patients with estrogen receptor–positive metastatic breast cancer unless improvement is medically necessary. Single-agent is preferable to combination chemotherapy, and longer planned duration improves outcome but must be balanced against toxicity. There is no single optimal first-line or subsequent-line chemotherapy, and choice of treatment will be determined by multiple factors including prior therapy, toxicity, performance status, comorbid conditions, and patient preference. The role of bevacizumab remains controversial. Other targeted therapies have not been shown to enhance chemotherapy outcomes in HER2-negative breast cancer, the researchers said.
The full guideline can be found on the Agency for Healthcare Research and Quality website.
A new guideline on identifying optimal chemotherapy and targeted therapy for women with human epidermal growth factor 2–negative or unknown advanced breast cancer has been released by the American Society of Clinical Oncology.
Endocrine therapy is preferable to chemotherapy as first-line treatment for patients with estrogen receptor–positive metastatic breast cancer unless improvement is medically necessary. Single-agent is preferable to combination chemotherapy, and longer planned duration improves outcome but must be balanced against toxicity. There is no single optimal first-line or subsequent-line chemotherapy, and choice of treatment will be determined by multiple factors including prior therapy, toxicity, performance status, comorbid conditions, and patient preference. The role of bevacizumab remains controversial. Other targeted therapies have not been shown to enhance chemotherapy outcomes in HER2-negative breast cancer, the researchers said.
The full guideline can be found on the Agency for Healthcare Research and Quality website.
A new guideline on identifying optimal chemotherapy and targeted therapy for women with human epidermal growth factor 2–negative or unknown advanced breast cancer has been released by the American Society of Clinical Oncology.
Endocrine therapy is preferable to chemotherapy as first-line treatment for patients with estrogen receptor–positive metastatic breast cancer unless improvement is medically necessary. Single-agent is preferable to combination chemotherapy, and longer planned duration improves outcome but must be balanced against toxicity. There is no single optimal first-line or subsequent-line chemotherapy, and choice of treatment will be determined by multiple factors including prior therapy, toxicity, performance status, comorbid conditions, and patient preference. The role of bevacizumab remains controversial. Other targeted therapies have not been shown to enhance chemotherapy outcomes in HER2-negative breast cancer, the researchers said.
The full guideline can be found on the Agency for Healthcare Research and Quality website.
Guideline clarifies first-line treatment for allergic rhinitis
First-line treatment for allergic rhinitis should include intranasal steroids, as well as less-sedating second-generation oral antihistamines for patients whose primary complaints are sneezing and itching, according to a new clinical practice guideline published online Feb. 2 in Otolaryngology–Head and Neck Surgery.
In contrast, sinonasal imaging should not be routine when patients first present with symptoms consistent with allergic rhinitis, and oral leukotriene receptor antagonists are not recommended as first-line therapy, said Dr. Michael D. Seidman of Henry Ford West Bloomfield (Mich.) Hospital and chair of the guideline working group, and his associates.
Dr. Seidman and a panel of 20 experts in otolaryngology, allergy and immunology, internal medicine, family medicine, pediatrics, sleep medicine, advanced practice nursing, complementary and alternative medicine, and consumer advocacy developed the new practice guideline to enable clinicians in all settings to improve patient care and reduce harmful or unnecessary variations in care for allergic rhinitis.
“The guideline is intended to focus on a limited number of quality improvement opportunities deemed most important by the working group and is not intended to be a comprehensive reference for diagnosing and managing allergic rhinitis,” the authors noted.
During the course of 1 year, the working group reviewed 1,605 randomized, controlled trials, 31 existing clinical practice guidelines, and 390 systematic reviews of the literature regarding allergic rhinitis in adults and children older than age 2 years. They then compiled 14 key recommendations that underwent extensive peer review, which have been published online and as a supplement to the February issue (Otolaryngol. Head Neck Surg. 2015;152:S1-S43).
In addition to the recommendations noted above, the guideline advises:
* Clinicians should diagnose allergic rhinitis when patients present with a history and physical exam consistent with the disorder (including clear rhinorrhea, nasal congestion, pale discoloration of the nasal mucosa, and red, watery eyes) plus symptoms of nasal congestion, runny nose, itchy nose, or sneezing.
* Clinicians should perform and interpret (or refer patients for) specific IgE allergy testing for allergic rhinitis that doesn’t respond to empiric treatment, or when the diagnosis is uncertain, or when identifying the specific causative allergen would allow targeted therapy.
* Clinicians should assess diagnosed patients for associated conditions such as asthma, atopic dermatitis, sleep-disordered breathing, conjunctivitis, rhinosinusitis, and otitis media, and should document that in the medical record.
* Clinicians should offer (or refer patients for) sublingual or subcutaneous immunotherapy when allergic rhinitis doesn’t respond adequately to pharmacologic therapy.
* Clinicians may advise avoidance of known allergens or controlling the patient’s environment by such measures as removing pets, using air filtration systems, using dust-mite–reducing covers for bedding, and using acaricides.
* Clinicians may offer intranasal antihistamines for patients with seasonal, perennial or episodic allergic rhinitis.*
* Clinicians may offer (or refer patients for) reduction of the inferior turbinates for patients who have nasal airway obstruction or enlarged turbinates.
* Clinicians may offer (or refer patient for) acupuncture if they are interested in nonpharmacologic therapy.
*Clinicians may offer combination pharmacologic therapy in patients with allergic rhinitis who have inadequate response to pharmacologic monotherapy.
The working group offered no recommendations concerning herbal therapy for allergic rhinitis, because of the limited literature on those substances and concern about their safety.
The full text of the guideline and its supporting data are available free of charge at www.entnet.org. In addition, an algorithm of the guideline’s action statements and a table of common allergic rhinitis clinical scenarios are available as quick reference guides for clinicians.
The American Academy of Otolaryngology–Head and Neck Surgery Foundation funded the guideline. Dr. Seidman reported being medical director of the Scientific Advisory Board of Visalus, founder of the Body Language Vitamin, and holder of six patents related to dietary supplements, aircraft, and middle ear and brain implants. His associates reported ties to Acclarent/Johnson/Johnson, FirstLine Medical, GlaxoSmithKline, Intersect, MEDA, Medtronic, Merck, Mylan, Novartis, TEVA, Transit of Venus, Sanofi, Sunovion Pharmaceuticals, and WellPoint.
*Correction, 2/18/2015: An earlier version of this story misstated the guideline for the use of intranasal antihistamines.
First-line treatment for allergic rhinitis should include intranasal steroids, as well as less-sedating second-generation oral antihistamines for patients whose primary complaints are sneezing and itching, according to a new clinical practice guideline published online Feb. 2 in Otolaryngology–Head and Neck Surgery.
In contrast, sinonasal imaging should not be routine when patients first present with symptoms consistent with allergic rhinitis, and oral leukotriene receptor antagonists are not recommended as first-line therapy, said Dr. Michael D. Seidman of Henry Ford West Bloomfield (Mich.) Hospital and chair of the guideline working group, and his associates.
Dr. Seidman and a panel of 20 experts in otolaryngology, allergy and immunology, internal medicine, family medicine, pediatrics, sleep medicine, advanced practice nursing, complementary and alternative medicine, and consumer advocacy developed the new practice guideline to enable clinicians in all settings to improve patient care and reduce harmful or unnecessary variations in care for allergic rhinitis.
“The guideline is intended to focus on a limited number of quality improvement opportunities deemed most important by the working group and is not intended to be a comprehensive reference for diagnosing and managing allergic rhinitis,” the authors noted.
During the course of 1 year, the working group reviewed 1,605 randomized, controlled trials, 31 existing clinical practice guidelines, and 390 systematic reviews of the literature regarding allergic rhinitis in adults and children older than age 2 years. They then compiled 14 key recommendations that underwent extensive peer review, which have been published online and as a supplement to the February issue (Otolaryngol. Head Neck Surg. 2015;152:S1-S43).
In addition to the recommendations noted above, the guideline advises:
* Clinicians should diagnose allergic rhinitis when patients present with a history and physical exam consistent with the disorder (including clear rhinorrhea, nasal congestion, pale discoloration of the nasal mucosa, and red, watery eyes) plus symptoms of nasal congestion, runny nose, itchy nose, or sneezing.
* Clinicians should perform and interpret (or refer patients for) specific IgE allergy testing for allergic rhinitis that doesn’t respond to empiric treatment, or when the diagnosis is uncertain, or when identifying the specific causative allergen would allow targeted therapy.
* Clinicians should assess diagnosed patients for associated conditions such as asthma, atopic dermatitis, sleep-disordered breathing, conjunctivitis, rhinosinusitis, and otitis media, and should document that in the medical record.
* Clinicians should offer (or refer patients for) sublingual or subcutaneous immunotherapy when allergic rhinitis doesn’t respond adequately to pharmacologic therapy.
* Clinicians may advise avoidance of known allergens or controlling the patient’s environment by such measures as removing pets, using air filtration systems, using dust-mite–reducing covers for bedding, and using acaricides.
* Clinicians may offer intranasal antihistamines for patients with seasonal, perennial or episodic allergic rhinitis.*
* Clinicians may offer (or refer patients for) reduction of the inferior turbinates for patients who have nasal airway obstruction or enlarged turbinates.
* Clinicians may offer (or refer patient for) acupuncture if they are interested in nonpharmacologic therapy.
*Clinicians may offer combination pharmacologic therapy in patients with allergic rhinitis who have inadequate response to pharmacologic monotherapy.
The working group offered no recommendations concerning herbal therapy for allergic rhinitis, because of the limited literature on those substances and concern about their safety.
The full text of the guideline and its supporting data are available free of charge at www.entnet.org. In addition, an algorithm of the guideline’s action statements and a table of common allergic rhinitis clinical scenarios are available as quick reference guides for clinicians.
The American Academy of Otolaryngology–Head and Neck Surgery Foundation funded the guideline. Dr. Seidman reported being medical director of the Scientific Advisory Board of Visalus, founder of the Body Language Vitamin, and holder of six patents related to dietary supplements, aircraft, and middle ear and brain implants. His associates reported ties to Acclarent/Johnson/Johnson, FirstLine Medical, GlaxoSmithKline, Intersect, MEDA, Medtronic, Merck, Mylan, Novartis, TEVA, Transit of Venus, Sanofi, Sunovion Pharmaceuticals, and WellPoint.
*Correction, 2/18/2015: An earlier version of this story misstated the guideline for the use of intranasal antihistamines.
First-line treatment for allergic rhinitis should include intranasal steroids, as well as less-sedating second-generation oral antihistamines for patients whose primary complaints are sneezing and itching, according to a new clinical practice guideline published online Feb. 2 in Otolaryngology–Head and Neck Surgery.
In contrast, sinonasal imaging should not be routine when patients first present with symptoms consistent with allergic rhinitis, and oral leukotriene receptor antagonists are not recommended as first-line therapy, said Dr. Michael D. Seidman of Henry Ford West Bloomfield (Mich.) Hospital and chair of the guideline working group, and his associates.
Dr. Seidman and a panel of 20 experts in otolaryngology, allergy and immunology, internal medicine, family medicine, pediatrics, sleep medicine, advanced practice nursing, complementary and alternative medicine, and consumer advocacy developed the new practice guideline to enable clinicians in all settings to improve patient care and reduce harmful or unnecessary variations in care for allergic rhinitis.
“The guideline is intended to focus on a limited number of quality improvement opportunities deemed most important by the working group and is not intended to be a comprehensive reference for diagnosing and managing allergic rhinitis,” the authors noted.
During the course of 1 year, the working group reviewed 1,605 randomized, controlled trials, 31 existing clinical practice guidelines, and 390 systematic reviews of the literature regarding allergic rhinitis in adults and children older than age 2 years. They then compiled 14 key recommendations that underwent extensive peer review, which have been published online and as a supplement to the February issue (Otolaryngol. Head Neck Surg. 2015;152:S1-S43).
In addition to the recommendations noted above, the guideline advises:
* Clinicians should diagnose allergic rhinitis when patients present with a history and physical exam consistent with the disorder (including clear rhinorrhea, nasal congestion, pale discoloration of the nasal mucosa, and red, watery eyes) plus symptoms of nasal congestion, runny nose, itchy nose, or sneezing.
* Clinicians should perform and interpret (or refer patients for) specific IgE allergy testing for allergic rhinitis that doesn’t respond to empiric treatment, or when the diagnosis is uncertain, or when identifying the specific causative allergen would allow targeted therapy.
* Clinicians should assess diagnosed patients for associated conditions such as asthma, atopic dermatitis, sleep-disordered breathing, conjunctivitis, rhinosinusitis, and otitis media, and should document that in the medical record.
* Clinicians should offer (or refer patients for) sublingual or subcutaneous immunotherapy when allergic rhinitis doesn’t respond adequately to pharmacologic therapy.
* Clinicians may advise avoidance of known allergens or controlling the patient’s environment by such measures as removing pets, using air filtration systems, using dust-mite–reducing covers for bedding, and using acaricides.
* Clinicians may offer intranasal antihistamines for patients with seasonal, perennial or episodic allergic rhinitis.*
* Clinicians may offer (or refer patients for) reduction of the inferior turbinates for patients who have nasal airway obstruction or enlarged turbinates.
* Clinicians may offer (or refer patient for) acupuncture if they are interested in nonpharmacologic therapy.
*Clinicians may offer combination pharmacologic therapy in patients with allergic rhinitis who have inadequate response to pharmacologic monotherapy.
The working group offered no recommendations concerning herbal therapy for allergic rhinitis, because of the limited literature on those substances and concern about their safety.
The full text of the guideline and its supporting data are available free of charge at www.entnet.org. In addition, an algorithm of the guideline’s action statements and a table of common allergic rhinitis clinical scenarios are available as quick reference guides for clinicians.
The American Academy of Otolaryngology–Head and Neck Surgery Foundation funded the guideline. Dr. Seidman reported being medical director of the Scientific Advisory Board of Visalus, founder of the Body Language Vitamin, and holder of six patents related to dietary supplements, aircraft, and middle ear and brain implants. His associates reported ties to Acclarent/Johnson/Johnson, FirstLine Medical, GlaxoSmithKline, Intersect, MEDA, Medtronic, Merck, Mylan, Novartis, TEVA, Transit of Venus, Sanofi, Sunovion Pharmaceuticals, and WellPoint.
*Correction, 2/18/2015: An earlier version of this story misstated the guideline for the use of intranasal antihistamines.
FROM OTOLARYNGOLOGY–HEAD AND NECK SURGERY
Key clinical point: First-line treatment for allergic rhinitis should include intranasal steroids and second-generation oral antihistamines, and should not include leukotriene receptor antagonists or sinonasal imaging studies.
Major finding: A panel of 20 experts took 1 year to review the literature and develop action items focusing on a limited number of quality improvement opportunities they deemed most important to improve patient care.
Data source: A review of 1,605 randomized, controlled trials, 31 sets of practice guidelines, and 390 systematic reviews regarding allergic rhinitis, and a compilation of 14 recommendations for managing the disorder.
Disclosures: The American Academy of Otolaryngology–Head and Neck Surgery Foundation funded the guideline. Dr. Seidman reported being medical director of the Scientific Advisory Board of Visalus, founder of the Body Language Vitamin, and holder of six patents related to dietary supplements, aircraft, and middle ear and brain implants. His associates reported ties to Acclarent/Johnson/Johnson, FirstLine Medical, GlaxoSmithKline, Intersect, MEDA, Medtronic, Merck, Mylan, Novartis, TEVA, Transit of Venus, Sanofi, Sunovion Pharmaceuticals, and WellPoint.
Medicine grapples with physician suicide
One day in 1986, a medical school classmate handed Dr. Robert P. Bright a gun that she intended to use to kill herself. She asked him to hold on to it for her and to keep quiet about her sense of hopelessness.
“She didn’t want anybody in the medical school to know; it was all hidden and hush-hushed,” recalled Dr. Bright, who is now a psychiatrist at the Mayo Clinic, Scottsdale, Ariz. “I was trying to juggle that with the issue of safety.”
He honored his classmate’s request for confidentiality, but he sought advice from the medical school dean about what to do. Before long, his classmate sought help from a psychiatrist and got better with medication and psychotherapy. “It turned out well, thank goodness,” Dr. Bright said.
Similar stories of despair among medical students and physicians don’t always end well. The American Foundation for Suicide Prevention estimates that 300-400 U.S. physicians commit suicide each year, about one per day. Suicide deaths are 250%-400% higher among female physicians, compared with women in other professions, and 70% higher among male physicians, compared with men in other professions. Major depression is a common risk factor, along with bipolar disorder and substance abuse.
Depression and other mood disorders may be underrecognized and inadequately treated in physicians because they may be reluctant to seek treatment, may attempt to diagnose and treat themselves, or may seek and receive “VIP treatment” from health care providers, according to a review article coauthored by Dr. Bright (Current Psych. 2011;10:16-30).
“Physicians struggling with these things are very much in the closet about it,” he said. “It’s a sad reflection on the stigma that’s still in our country that people can’t come forth and say, ‘I’m struggling with depression or anxiety.’ ”
Researchers led by Dr. Katherine J. Gold at the University of Michigan used data from the National Violent Death Reporting System to evaluate suicide among physicians and found that job stressors “may impact physician identity and be a particular risk factor for which more attention is warranted” (Gen. Hosp. Psychiatry 2013;35:45-9).
Work dissatisfaction sent Dr. Pamela Wible into a tailspin early in her career. In 2004 she found herself in a suicidal state for about 6 weeks, “I stayed at home, crying myself into my pillow and I never sought help from my colleagues,” recalled Dr. Wible, a family physician in Eugene, Ore., who currently leads training sessions in medical student and physician suicide prevention. “I was not depressed before entering the medical profession, but [I had developed] constant thoughts of ‘Can I just disappear? What’s the easiest way to do this?’ I got to a place of complete surrender but I didn’t have the gun. I didn’t have the stockpile of pills. I didn’t have a follow-through on the plan.”
Instead of taking her own life, she “had an epiphany” and changed the way she practiced medicine. She said that owning her own clinic empowered her to “become the doctor I had originally described on my personal statement when I entered medical school.”
According to Dr. Charles F. Reynolds III, a psychiatrist at the University of Pittsburgh, reluctance to seek treatment can also be driven by concerns about the amount of time that treatment could take.
“As physicians, we often don’t appropriately take care of ourselves when it comes to issues like depression,” said Dr. Reynolds, who also directs the National Institute of Mental Health–sponsored Center of Excellence in the Prevention and Treatment of Late Life Mood Disorders. “We may still see it as a character weakness rather than as a medical illness that can be diagnosed and appropriately treated. Concerns about privacy also figure into the concerns of some physicians as well.”
Practicing in a rural area or small community can also be an obstacle to treatment, not only because of limited access to psychiatrists, but because the “patient” may be the only physician in town.
“As much as there’s stigma for everybody being voluntarily or involuntarily admitted [for suicidal ideation], it’s a little different when you’re a provider within the hospital where you’re seeking care,” Dr. Bright noted.
He said that if he had the opportunity to counsel physicians experiencing suicidal thoughts, he would “remind them of the medical nature of depression, that the brain is just another organ and the organ is not making chemicals just like the pancreas doesn’t make insulin in diabetes,” he said. “I’d also encourage them to get the treatment that they need. I would encourage compassion for themselves that they would give to anybody else in the same situation.”
He said that he would advise them to find a mental health provider “that they trust with confidentiality, and to reach out to other people for support. I would also let them know about the physician assistance programs that are available. There’s one through Vanderbilt (the Vanderbilt Center for Professional Health) and several others that specialize in working with physicians who are struggling with mental health or substance abuse or disruptive behavior.”
Dr. Reynolds’ core message to distressed physicians is that “you’re a better doctor for your patients, and a better father or mother for your family, if you’re taking good care of yourself,” he said. “It’s hard for you to take care of your patients if you’re not also taking care of yourself, if you’re burning out. Get help. Treatment works.”
Dr. Christine Moutier, chief medical officer of the American Foundation for Suicide Prevention, added that troubled physicians “should feel no shame for the fact that they’re in distress. Any of us can get there through a whole variety of different pathways that life presents. There’s science and data to support this experience as commonplace and having underpinnings that are of no fault to anyone. That’s the reality.”
Dr. Wible, who has lost several colleagues and physician friends to suicide, said that she hopes for a more transparent discussion of the topic by the medical profession. She presented on the topic at the 2014 annual scientific assembly of the American Academy of Family Physicians.
“The talk before mine was on Ebola, and every seat was taken” in the 900-seat room. When it came time for her presentation, “I maybe had 100 people in the room. Now, are physicians more likely to die from Ebola or from suicide? We are in a state of denial. If we don’t talk about suicide, we will continue to lose one or two medical students or doctors every day. The sooner we talk about this and connect with each other outside of a PowerPoint presentation, the sooner we’re going to solve this.”
After a physician in a large clinical department at the University of Pittsburgh took his own life several years ago, the chair of that department invited Dr. Reynolds to speak with his staff. The meeting “was primarily educational in nature, so we talked about the topic, to try to destigmatize and to educate people about the need for appropriate help-seeking,” recalled Dr. Reynolds, who is a former president of the American College of Psychiatrists. “If the leadership of a medical institution appropriately sanctions help-seeking behavior and treatment of mental disorders like depression, that’s going to make it okay for people to reach out and seek help rather than pushing it under the rug, so to speak. If the leadership says ‘this is a key thing and we don’t think you can function adequately as a medical student or as a physician if you’re not taking appropriate care of yourself,’ that helps to shift the culture.”
The ripple effect of that kind of message from health care administrators can’t be underestimated, said Dr. Moutier, who helped launch a suicide and depression awareness program at the University of California, San Diego (Acad. Med. 2012;87:320-6). She encouraged health care leaders to stage periodic grand rounds and lectures for their medical staff about physician well-being, burnout, and the risk of suicide. “If the leader is uncomfortable talking about these things, that’s a sign they should get a little education for themselves about [these topics],” she said.
Dr. Reynolds noted that certain state medical licensure boards including those for Arkansas and Pennsylvania have incorporated destigmatizing language into relicensure exams. “Some of them previously would ask questions such as whether the applicants had a history of a mental disorder like depression,” he said. “What you’re beginning to see now increasingly is that the state medical board will ask more generic questions, like ‘Do you have any conditions that would interfere with the practice of your specialty in medicine?’ This is a good thing.”
He said that he is optimistic about future of physician well-being, noting that the University of Pittsburgh and other medical schools have incorporated wellness principles into first-year curriculum. “We underscore the importance of students becoming sensitive to one another, learning how to recognize depression in each other and creating a culture in which students can encourage each other to engage in appropriate help-seeking,” Dr. Reynolds explained. “I think we are witnessing a shift in the culture of institutional medicine as we bring along new generations of physicians who are better educated about mental disorders and their treatment and issues related to suicide as we reach out to students, make counseling services available to them, educate them about these issues. That supports a cultural shift that gradually erodes the issue of stigma that has so long plagued appropriate help-seeking in medical institutions.”
Still, Dr. Wible said that she worries about the disaffected colleagues who reach out to her almost every day. “Just yesterday I got an e-mail from a physician in Oklahoma who told me they just lost three physicians to suicide in 1 month who were on probation with the medical board,” she said. “These are not defective physicians. These people need to be helped.”
Dr. Wible said that she favors holding periodic panel discussions on the topics of depression and physician suicide for medical students and physicians alike. “Let other physicians who’ve been depressed and suicidal sit in front of the room on the first week of medical school, or in a hospital once in a while, mandatory, where you listen to other well-respected physicians say, ‘yeah. I cried myself to sleep after I lost this patient,’ or ‘I had suicidal thoughts during a malpractice case.’ There are lots of reasons why physicians could be sad. They need to start talking about it publicly. Other medical students and physicians would then feel comfortable to raise their hands in the audience and say, ‘I felt the same way.’ ”
Suggested resources for help
American Foundation for Suicide Prevention (www.afsp.org/).
24-hour crisis line: 1-800-273-TALK (8255).
In 2008 the AFSP released a documentary about the problem of physician depression and suicide titled “Struggling in Silence,” which aired on public television stations nationwide and is available on DVD for $24.99.
Center for Patient and Professional Advocacy (www.mc.vanderbilt.edu/centers/cppa/index.php)
Depression and Bipolar Support Alliance (www.dbsalliance.org).
Federation of State Physician Health Programs Inc. (www.fsphp.org).
Vanderbilt Center for Professional Health (www.mc.vanderbilt.edu/cph).
The Mayo Clinic Program on Physician Well-Being (http://www.mayo.edu/research/centers-programs/physician-well-being-program/overview).
ePhysicianHealth.com, a program of the Ontario Medical Association (http://php.oma.org/ePhysicianHealth.html)
The Academic Medicine Handbook: A Guide to Achievement and Fulfillment for Academic Faculty, New York: Springer, 2013 (http://www.springer.com/medicine/internal/book/978-1-4614-5692-6)
dbrunk@frontlinemedcom.com
On Twitter @dougbrunk
As a specialist in physician health, I shout out that we can never have too many articles on this heartbreaking tragedy that claims so many lives each year - and leaves so many devastated people in its wake.
 |
| Dr. Michael F. Myers |
It is sobering and frightening that despite the excellent institutional and systemic changes outlined by Dr. Reynolds and Dr. Moutier and the moving first-hand testimonials of Dr. Bright and Dr. Wible, despairing doctors continue to die by their own hands. The loss of so many intelligent, highly trained, and compassionate caregivers is mind-numbing and unconscionable. We cannot afford to let down our guard.
As part of my research for a book in progress "When Physicians Kill Themselves: The Voices of Those They Leave Behind," I have been interviewing the family members and medical colleagues of doctors who have died by suicide.
One theme that is ascendant is how commonly the ailing physician has fallen through the cracks. Initially, he may not recognize or accept that he is burned out, depressed, or abusing alcohol and other drugs. When she does begin to understand what her symptoms suggest, the internalized stigma is so harsh and relentless that seeking help is out of the question. This drives self-medicating, but even when this does not occur and he consults a psychiatrist, punishing shame colors and works against forming a therapeutic alliance, accepting the diagnosis, keeping appointments, disclosing dangerous suicidality, adhering to medication, engaging in lifesaving psychotherapy and maintaining (or regaining) hope.
What makes matters worse is when the treating professional cuts corners (or enables self-defeating behaviors in the patient) and does not use the same judgment, monitoring, and vigilance that she uses with her nonphysician patients.
What I have found most disturbing in these narratives of my interviewees is how often their attempts to access their loved one's caregiver have fallen on deaf ears. This has to stop.
Dr. Wible says that she "had an epiphany" and changed the way she practiced medicine. It is our duty to reach out and help more physicians find their epiphany.
Dr. Michael F. Myers is professor of clinical psychiatry at SUNY Downstate Medical Center in Brooklyn, N.Y. He also is the coauthor (with Carla Fine) of "Touched by Suicide: Hope and Healing After Loss" and (with Dr. Glen O. Gabbard) of "The Physician as Patient: A Clinical Handbook for Mental Health Professionals."
As a specialist in physician health, I shout out that we can never have too many articles on this heartbreaking tragedy that claims so many lives each year - and leaves so many devastated people in its wake.
|
| Dr. Michael F. Myers |
It is sobering and frightening that despite the excellent institutional and systemic changes outlined by Dr. Reynolds and Dr. Moutier and the moving first-hand testimonials of Dr. Bright and Dr. Wible, despairing doctors continue to die by their own hands. The loss of so many intelligent, highly trained, and compassionate caregivers is mind-numbing and unconscionable. We cannot afford to let down our guard.
As part of my research for a book in progress "When Physicians Kill Themselves: The Voices of Those They Leave Behind," I have been interviewing the family members and medical colleagues of doctors who have died by suicide.
One theme that is ascendant is how commonly the ailing physician has fallen through the cracks. Initially, he may not recognize or accept that he is burned out, depressed, or abusing alcohol and other drugs. When she does begin to understand what her symptoms suggest, the internalized stigma is so harsh and relentless that seeking help is out of the question. This drives self-medicating, but even when this does not occur and he consults a psychiatrist, punishing shame colors and works against forming a therapeutic alliance, accepting the diagnosis, keeping appointments, disclosing dangerous suicidality, adhering to medication, engaging in lifesaving psychotherapy and maintaining (or regaining) hope.
What makes matters worse is when the treating professional cuts corners (or enables self-defeating behaviors in the patient) and does not use the same judgment, monitoring, and vigilance that she uses with her nonphysician patients.
What I have found most disturbing in these narratives of my interviewees is how often their attempts to access their loved one's caregiver have fallen on deaf ears. This has to stop.
Dr. Wible says that she "had an epiphany" and changed the way she practiced medicine. It is our duty to reach out and help more physicians find their epiphany.
Dr. Michael F. Myers is professor of clinical psychiatry at SUNY Downstate Medical Center in Brooklyn, N.Y. He also is the coauthor (with Carla Fine) of "Touched by Suicide: Hope and Healing After Loss" and (with Dr. Glen O. Gabbard) of "The Physician as Patient: A Clinical Handbook for Mental Health Professionals."
As a specialist in physician health, I shout out that we can never have too many articles on this heartbreaking tragedy that claims so many lives each year - and leaves so many devastated people in its wake.
|
| Dr. Michael F. Myers |
It is sobering and frightening that despite the excellent institutional and systemic changes outlined by Dr. Reynolds and Dr. Moutier and the moving first-hand testimonials of Dr. Bright and Dr. Wible, despairing doctors continue to die by their own hands. The loss of so many intelligent, highly trained, and compassionate caregivers is mind-numbing and unconscionable. We cannot afford to let down our guard.
As part of my research for a book in progress "When Physicians Kill Themselves: The Voices of Those They Leave Behind," I have been interviewing the family members and medical colleagues of doctors who have died by suicide.
One theme that is ascendant is how commonly the ailing physician has fallen through the cracks. Initially, he may not recognize or accept that he is burned out, depressed, or abusing alcohol and other drugs. When she does begin to understand what her symptoms suggest, the internalized stigma is so harsh and relentless that seeking help is out of the question. This drives self-medicating, but even when this does not occur and he consults a psychiatrist, punishing shame colors and works against forming a therapeutic alliance, accepting the diagnosis, keeping appointments, disclosing dangerous suicidality, adhering to medication, engaging in lifesaving psychotherapy and maintaining (or regaining) hope.
What makes matters worse is when the treating professional cuts corners (or enables self-defeating behaviors in the patient) and does not use the same judgment, monitoring, and vigilance that she uses with her nonphysician patients.
What I have found most disturbing in these narratives of my interviewees is how often their attempts to access their loved one's caregiver have fallen on deaf ears. This has to stop.
Dr. Wible says that she "had an epiphany" and changed the way she practiced medicine. It is our duty to reach out and help more physicians find their epiphany.
Dr. Michael F. Myers is professor of clinical psychiatry at SUNY Downstate Medical Center in Brooklyn, N.Y. He also is the coauthor (with Carla Fine) of "Touched by Suicide: Hope and Healing After Loss" and (with Dr. Glen O. Gabbard) of "The Physician as Patient: A Clinical Handbook for Mental Health Professionals."
One day in 1986, a medical school classmate handed Dr. Robert P. Bright a gun that she intended to use to kill herself. She asked him to hold on to it for her and to keep quiet about her sense of hopelessness.
“She didn’t want anybody in the medical school to know; it was all hidden and hush-hushed,” recalled Dr. Bright, who is now a psychiatrist at the Mayo Clinic, Scottsdale, Ariz. “I was trying to juggle that with the issue of safety.”
He honored his classmate’s request for confidentiality, but he sought advice from the medical school dean about what to do. Before long, his classmate sought help from a psychiatrist and got better with medication and psychotherapy. “It turned out well, thank goodness,” Dr. Bright said.
Similar stories of despair among medical students and physicians don’t always end well. The American Foundation for Suicide Prevention estimates that 300-400 U.S. physicians commit suicide each year, about one per day. Suicide deaths are 250%-400% higher among female physicians, compared with women in other professions, and 70% higher among male physicians, compared with men in other professions. Major depression is a common risk factor, along with bipolar disorder and substance abuse.
Depression and other mood disorders may be underrecognized and inadequately treated in physicians because they may be reluctant to seek treatment, may attempt to diagnose and treat themselves, or may seek and receive “VIP treatment” from health care providers, according to a review article coauthored by Dr. Bright (Current Psych. 2011;10:16-30).
“Physicians struggling with these things are very much in the closet about it,” he said. “It’s a sad reflection on the stigma that’s still in our country that people can’t come forth and say, ‘I’m struggling with depression or anxiety.’ ”
Researchers led by Dr. Katherine J. Gold at the University of Michigan used data from the National Violent Death Reporting System to evaluate suicide among physicians and found that job stressors “may impact physician identity and be a particular risk factor for which more attention is warranted” (Gen. Hosp. Psychiatry 2013;35:45-9).
Work dissatisfaction sent Dr. Pamela Wible into a tailspin early in her career. In 2004 she found herself in a suicidal state for about 6 weeks, “I stayed at home, crying myself into my pillow and I never sought help from my colleagues,” recalled Dr. Wible, a family physician in Eugene, Ore., who currently leads training sessions in medical student and physician suicide prevention. “I was not depressed before entering the medical profession, but [I had developed] constant thoughts of ‘Can I just disappear? What’s the easiest way to do this?’ I got to a place of complete surrender but I didn’t have the gun. I didn’t have the stockpile of pills. I didn’t have a follow-through on the plan.”
Instead of taking her own life, she “had an epiphany” and changed the way she practiced medicine. She said that owning her own clinic empowered her to “become the doctor I had originally described on my personal statement when I entered medical school.”
According to Dr. Charles F. Reynolds III, a psychiatrist at the University of Pittsburgh, reluctance to seek treatment can also be driven by concerns about the amount of time that treatment could take.
“As physicians, we often don’t appropriately take care of ourselves when it comes to issues like depression,” said Dr. Reynolds, who also directs the National Institute of Mental Health–sponsored Center of Excellence in the Prevention and Treatment of Late Life Mood Disorders. “We may still see it as a character weakness rather than as a medical illness that can be diagnosed and appropriately treated. Concerns about privacy also figure into the concerns of some physicians as well.”
Practicing in a rural area or small community can also be an obstacle to treatment, not only because of limited access to psychiatrists, but because the “patient” may be the only physician in town.
“As much as there’s stigma for everybody being voluntarily or involuntarily admitted [for suicidal ideation], it’s a little different when you’re a provider within the hospital where you’re seeking care,” Dr. Bright noted.
He said that if he had the opportunity to counsel physicians experiencing suicidal thoughts, he would “remind them of the medical nature of depression, that the brain is just another organ and the organ is not making chemicals just like the pancreas doesn’t make insulin in diabetes,” he said. “I’d also encourage them to get the treatment that they need. I would encourage compassion for themselves that they would give to anybody else in the same situation.”
He said that he would advise them to find a mental health provider “that they trust with confidentiality, and to reach out to other people for support. I would also let them know about the physician assistance programs that are available. There’s one through Vanderbilt (the Vanderbilt Center for Professional Health) and several others that specialize in working with physicians who are struggling with mental health or substance abuse or disruptive behavior.”
Dr. Reynolds’ core message to distressed physicians is that “you’re a better doctor for your patients, and a better father or mother for your family, if you’re taking good care of yourself,” he said. “It’s hard for you to take care of your patients if you’re not also taking care of yourself, if you’re burning out. Get help. Treatment works.”
Dr. Christine Moutier, chief medical officer of the American Foundation for Suicide Prevention, added that troubled physicians “should feel no shame for the fact that they’re in distress. Any of us can get there through a whole variety of different pathways that life presents. There’s science and data to support this experience as commonplace and having underpinnings that are of no fault to anyone. That’s the reality.”
Dr. Wible, who has lost several colleagues and physician friends to suicide, said that she hopes for a more transparent discussion of the topic by the medical profession. She presented on the topic at the 2014 annual scientific assembly of the American Academy of Family Physicians.
“The talk before mine was on Ebola, and every seat was taken” in the 900-seat room. When it came time for her presentation, “I maybe had 100 people in the room. Now, are physicians more likely to die from Ebola or from suicide? We are in a state of denial. If we don’t talk about suicide, we will continue to lose one or two medical students or doctors every day. The sooner we talk about this and connect with each other outside of a PowerPoint presentation, the sooner we’re going to solve this.”
After a physician in a large clinical department at the University of Pittsburgh took his own life several years ago, the chair of that department invited Dr. Reynolds to speak with his staff. The meeting “was primarily educational in nature, so we talked about the topic, to try to destigmatize and to educate people about the need for appropriate help-seeking,” recalled Dr. Reynolds, who is a former president of the American College of Psychiatrists. “If the leadership of a medical institution appropriately sanctions help-seeking behavior and treatment of mental disorders like depression, that’s going to make it okay for people to reach out and seek help rather than pushing it under the rug, so to speak. If the leadership says ‘this is a key thing and we don’t think you can function adequately as a medical student or as a physician if you’re not taking appropriate care of yourself,’ that helps to shift the culture.”
The ripple effect of that kind of message from health care administrators can’t be underestimated, said Dr. Moutier, who helped launch a suicide and depression awareness program at the University of California, San Diego (Acad. Med. 2012;87:320-6). She encouraged health care leaders to stage periodic grand rounds and lectures for their medical staff about physician well-being, burnout, and the risk of suicide. “If the leader is uncomfortable talking about these things, that’s a sign they should get a little education for themselves about [these topics],” she said.
Dr. Reynolds noted that certain state medical licensure boards including those for Arkansas and Pennsylvania have incorporated destigmatizing language into relicensure exams. “Some of them previously would ask questions such as whether the applicants had a history of a mental disorder like depression,” he said. “What you’re beginning to see now increasingly is that the state medical board will ask more generic questions, like ‘Do you have any conditions that would interfere with the practice of your specialty in medicine?’ This is a good thing.”
He said that he is optimistic about future of physician well-being, noting that the University of Pittsburgh and other medical schools have incorporated wellness principles into first-year curriculum. “We underscore the importance of students becoming sensitive to one another, learning how to recognize depression in each other and creating a culture in which students can encourage each other to engage in appropriate help-seeking,” Dr. Reynolds explained. “I think we are witnessing a shift in the culture of institutional medicine as we bring along new generations of physicians who are better educated about mental disorders and their treatment and issues related to suicide as we reach out to students, make counseling services available to them, educate them about these issues. That supports a cultural shift that gradually erodes the issue of stigma that has so long plagued appropriate help-seeking in medical institutions.”
Still, Dr. Wible said that she worries about the disaffected colleagues who reach out to her almost every day. “Just yesterday I got an e-mail from a physician in Oklahoma who told me they just lost three physicians to suicide in 1 month who were on probation with the medical board,” she said. “These are not defective physicians. These people need to be helped.”
Dr. Wible said that she favors holding periodic panel discussions on the topics of depression and physician suicide for medical students and physicians alike. “Let other physicians who’ve been depressed and suicidal sit in front of the room on the first week of medical school, or in a hospital once in a while, mandatory, where you listen to other well-respected physicians say, ‘yeah. I cried myself to sleep after I lost this patient,’ or ‘I had suicidal thoughts during a malpractice case.’ There are lots of reasons why physicians could be sad. They need to start talking about it publicly. Other medical students and physicians would then feel comfortable to raise their hands in the audience and say, ‘I felt the same way.’ ”
Suggested resources for help
American Foundation for Suicide Prevention (www.afsp.org/).
24-hour crisis line: 1-800-273-TALK (8255).
In 2008 the AFSP released a documentary about the problem of physician depression and suicide titled “Struggling in Silence,” which aired on public television stations nationwide and is available on DVD for $24.99.
Center for Patient and Professional Advocacy (www.mc.vanderbilt.edu/centers/cppa/index.php)
Depression and Bipolar Support Alliance (www.dbsalliance.org).
Federation of State Physician Health Programs Inc. (www.fsphp.org).
Vanderbilt Center for Professional Health (www.mc.vanderbilt.edu/cph).
The Mayo Clinic Program on Physician Well-Being (http://www.mayo.edu/research/centers-programs/physician-well-being-program/overview).
ePhysicianHealth.com, a program of the Ontario Medical Association (http://php.oma.org/ePhysicianHealth.html)
The Academic Medicine Handbook: A Guide to Achievement and Fulfillment for Academic Faculty, New York: Springer, 2013 (http://www.springer.com/medicine/internal/book/978-1-4614-5692-6)
dbrunk@frontlinemedcom.com
On Twitter @dougbrunk
One day in 1986, a medical school classmate handed Dr. Robert P. Bright a gun that she intended to use to kill herself. She asked him to hold on to it for her and to keep quiet about her sense of hopelessness.
“She didn’t want anybody in the medical school to know; it was all hidden and hush-hushed,” recalled Dr. Bright, who is now a psychiatrist at the Mayo Clinic, Scottsdale, Ariz. “I was trying to juggle that with the issue of safety.”
He honored his classmate’s request for confidentiality, but he sought advice from the medical school dean about what to do. Before long, his classmate sought help from a psychiatrist and got better with medication and psychotherapy. “It turned out well, thank goodness,” Dr. Bright said.
Similar stories of despair among medical students and physicians don’t always end well. The American Foundation for Suicide Prevention estimates that 300-400 U.S. physicians commit suicide each year, about one per day. Suicide deaths are 250%-400% higher among female physicians, compared with women in other professions, and 70% higher among male physicians, compared with men in other professions. Major depression is a common risk factor, along with bipolar disorder and substance abuse.
Depression and other mood disorders may be underrecognized and inadequately treated in physicians because they may be reluctant to seek treatment, may attempt to diagnose and treat themselves, or may seek and receive “VIP treatment” from health care providers, according to a review article coauthored by Dr. Bright (Current Psych. 2011;10:16-30).
“Physicians struggling with these things are very much in the closet about it,” he said. “It’s a sad reflection on the stigma that’s still in our country that people can’t come forth and say, ‘I’m struggling with depression or anxiety.’ ”
Researchers led by Dr. Katherine J. Gold at the University of Michigan used data from the National Violent Death Reporting System to evaluate suicide among physicians and found that job stressors “may impact physician identity and be a particular risk factor for which more attention is warranted” (Gen. Hosp. Psychiatry 2013;35:45-9).
Work dissatisfaction sent Dr. Pamela Wible into a tailspin early in her career. In 2004 she found herself in a suicidal state for about 6 weeks, “I stayed at home, crying myself into my pillow and I never sought help from my colleagues,” recalled Dr. Wible, a family physician in Eugene, Ore., who currently leads training sessions in medical student and physician suicide prevention. “I was not depressed before entering the medical profession, but [I had developed] constant thoughts of ‘Can I just disappear? What’s the easiest way to do this?’ I got to a place of complete surrender but I didn’t have the gun. I didn’t have the stockpile of pills. I didn’t have a follow-through on the plan.”
Instead of taking her own life, she “had an epiphany” and changed the way she practiced medicine. She said that owning her own clinic empowered her to “become the doctor I had originally described on my personal statement when I entered medical school.”
According to Dr. Charles F. Reynolds III, a psychiatrist at the University of Pittsburgh, reluctance to seek treatment can also be driven by concerns about the amount of time that treatment could take.
“As physicians, we often don’t appropriately take care of ourselves when it comes to issues like depression,” said Dr. Reynolds, who also directs the National Institute of Mental Health–sponsored Center of Excellence in the Prevention and Treatment of Late Life Mood Disorders. “We may still see it as a character weakness rather than as a medical illness that can be diagnosed and appropriately treated. Concerns about privacy also figure into the concerns of some physicians as well.”
Practicing in a rural area or small community can also be an obstacle to treatment, not only because of limited access to psychiatrists, but because the “patient” may be the only physician in town.
“As much as there’s stigma for everybody being voluntarily or involuntarily admitted [for suicidal ideation], it’s a little different when you’re a provider within the hospital where you’re seeking care,” Dr. Bright noted.
He said that if he had the opportunity to counsel physicians experiencing suicidal thoughts, he would “remind them of the medical nature of depression, that the brain is just another organ and the organ is not making chemicals just like the pancreas doesn’t make insulin in diabetes,” he said. “I’d also encourage them to get the treatment that they need. I would encourage compassion for themselves that they would give to anybody else in the same situation.”
He said that he would advise them to find a mental health provider “that they trust with confidentiality, and to reach out to other people for support. I would also let them know about the physician assistance programs that are available. There’s one through Vanderbilt (the Vanderbilt Center for Professional Health) and several others that specialize in working with physicians who are struggling with mental health or substance abuse or disruptive behavior.”
Dr. Reynolds’ core message to distressed physicians is that “you’re a better doctor for your patients, and a better father or mother for your family, if you’re taking good care of yourself,” he said. “It’s hard for you to take care of your patients if you’re not also taking care of yourself, if you’re burning out. Get help. Treatment works.”
Dr. Christine Moutier, chief medical officer of the American Foundation for Suicide Prevention, added that troubled physicians “should feel no shame for the fact that they’re in distress. Any of us can get there through a whole variety of different pathways that life presents. There’s science and data to support this experience as commonplace and having underpinnings that are of no fault to anyone. That’s the reality.”
Dr. Wible, who has lost several colleagues and physician friends to suicide, said that she hopes for a more transparent discussion of the topic by the medical profession. She presented on the topic at the 2014 annual scientific assembly of the American Academy of Family Physicians.
“The talk before mine was on Ebola, and every seat was taken” in the 900-seat room. When it came time for her presentation, “I maybe had 100 people in the room. Now, are physicians more likely to die from Ebola or from suicide? We are in a state of denial. If we don’t talk about suicide, we will continue to lose one or two medical students or doctors every day. The sooner we talk about this and connect with each other outside of a PowerPoint presentation, the sooner we’re going to solve this.”
After a physician in a large clinical department at the University of Pittsburgh took his own life several years ago, the chair of that department invited Dr. Reynolds to speak with his staff. The meeting “was primarily educational in nature, so we talked about the topic, to try to destigmatize and to educate people about the need for appropriate help-seeking,” recalled Dr. Reynolds, who is a former president of the American College of Psychiatrists. “If the leadership of a medical institution appropriately sanctions help-seeking behavior and treatment of mental disorders like depression, that’s going to make it okay for people to reach out and seek help rather than pushing it under the rug, so to speak. If the leadership says ‘this is a key thing and we don’t think you can function adequately as a medical student or as a physician if you’re not taking appropriate care of yourself,’ that helps to shift the culture.”
The ripple effect of that kind of message from health care administrators can’t be underestimated, said Dr. Moutier, who helped launch a suicide and depression awareness program at the University of California, San Diego (Acad. Med. 2012;87:320-6). She encouraged health care leaders to stage periodic grand rounds and lectures for their medical staff about physician well-being, burnout, and the risk of suicide. “If the leader is uncomfortable talking about these things, that’s a sign they should get a little education for themselves about [these topics],” she said.
Dr. Reynolds noted that certain state medical licensure boards including those for Arkansas and Pennsylvania have incorporated destigmatizing language into relicensure exams. “Some of them previously would ask questions such as whether the applicants had a history of a mental disorder like depression,” he said. “What you’re beginning to see now increasingly is that the state medical board will ask more generic questions, like ‘Do you have any conditions that would interfere with the practice of your specialty in medicine?’ This is a good thing.”
He said that he is optimistic about future of physician well-being, noting that the University of Pittsburgh and other medical schools have incorporated wellness principles into first-year curriculum. “We underscore the importance of students becoming sensitive to one another, learning how to recognize depression in each other and creating a culture in which students can encourage each other to engage in appropriate help-seeking,” Dr. Reynolds explained. “I think we are witnessing a shift in the culture of institutional medicine as we bring along new generations of physicians who are better educated about mental disorders and their treatment and issues related to suicide as we reach out to students, make counseling services available to them, educate them about these issues. That supports a cultural shift that gradually erodes the issue of stigma that has so long plagued appropriate help-seeking in medical institutions.”
Still, Dr. Wible said that she worries about the disaffected colleagues who reach out to her almost every day. “Just yesterday I got an e-mail from a physician in Oklahoma who told me they just lost three physicians to suicide in 1 month who were on probation with the medical board,” she said. “These are not defective physicians. These people need to be helped.”
Dr. Wible said that she favors holding periodic panel discussions on the topics of depression and physician suicide for medical students and physicians alike. “Let other physicians who’ve been depressed and suicidal sit in front of the room on the first week of medical school, or in a hospital once in a while, mandatory, where you listen to other well-respected physicians say, ‘yeah. I cried myself to sleep after I lost this patient,’ or ‘I had suicidal thoughts during a malpractice case.’ There are lots of reasons why physicians could be sad. They need to start talking about it publicly. Other medical students and physicians would then feel comfortable to raise their hands in the audience and say, ‘I felt the same way.’ ”
Suggested resources for help
American Foundation for Suicide Prevention (www.afsp.org/).
24-hour crisis line: 1-800-273-TALK (8255).
In 2008 the AFSP released a documentary about the problem of physician depression and suicide titled “Struggling in Silence,” which aired on public television stations nationwide and is available on DVD for $24.99.
Center for Patient and Professional Advocacy (www.mc.vanderbilt.edu/centers/cppa/index.php)
Depression and Bipolar Support Alliance (www.dbsalliance.org).
Federation of State Physician Health Programs Inc. (www.fsphp.org).
Vanderbilt Center for Professional Health (www.mc.vanderbilt.edu/cph).
The Mayo Clinic Program on Physician Well-Being (http://www.mayo.edu/research/centers-programs/physician-well-being-program/overview).
ePhysicianHealth.com, a program of the Ontario Medical Association (http://php.oma.org/ePhysicianHealth.html)
The Academic Medicine Handbook: A Guide to Achievement and Fulfillment for Academic Faculty, New York: Springer, 2013 (http://www.springer.com/medicine/internal/book/978-1-4614-5692-6)
dbrunk@frontlinemedcom.com
On Twitter @dougbrunk
2013 AHA/ACC/TOS guideline for the management of overweight and obesity in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society
Recommendations
Each recommendation has been mapped from the NHLBI grading format to the American College of Cardiology/American Heart Association Class of Recommendation/Level of Evidence (ACC/AHA COR/LOE) construct and is expressed in both formats. Because of the inherent differences in grading systems and the clinical questions driving the recommendations, alignment between the NHLBI and ACC/AHA formats is in some cases imperfect. Definitions for the NHLBI strength of recommendation (A-E, N) and quality of evidence (High, Moderate, Low) and the ACC/AHA levels of the evidence (LOE: A-C) and classes of recommendations (COR: I-III) are provided at the end of the "Major Recommendations" field.
Summary of Recommendations for Obesity
Identifying Patients Who Need to Lose Weight (Body Mass Index [BMI] and Waist Circumference)
1a. Measure height and weight and calculate BMI at annual visits or more frequently. NHLBI Grade: E (Expert Opinion); ACC/AHA COR: I; ACC/AHA LOE: C
1b. Use the current cutpoints for overweight (BMI 25.0–29.9 kg/m2) and obesity (BMI ≥30 kg/m2) to identify adults who may be at elevated risk of cardiovascular disease (CVD) and the current cutpoints for obesity (BMI ≥30 kg/m2) to identify adults who may be at elevated risk of mortality from all causes. NHLBI Grade: A (Strong); ACC/AHA COR: I; ACC/AHA LOE: B
1c. Advise overweight and obese adults that the greater the BMI, the greater the risk of CVD, type 2 diabetes, and all-cause mortality. NHLBI Grade: A (Strong) ACC/AHA COR: I; ACC/AHA LOE: B
1d. Measure waist circumference at annual visits or more frequently in overweight and obese adults. Advise adults that the greater the waist circumference, the greater the risk of CVD, type 2 diabetes, and all-cause mortality. The cutpoints currently in common use (from either National Institutes of Health [NIH]/NHLBI or World Health Organization/International Diabetes Federation [WHO/IDF]) may continue to be used to identify patients who may be at increased risk until further evidence becomes available. NHLBI Grade: E (Expert Opinion); ACC/AHA COR: IIa; ACC/AHA LOE: B
Matching Treatment Benefits with Risk Profiles (Reduction in Body Weight Effect on Risk Factors for CVD, Events, Morbidity and Mortality)
2. Counsel overweight and obese adults with cardiovascular risk factors (high blood pressure [BP], hyperlipidemia, and hyperglycemia) that lifestyle changes that produce even modest, sustained weight loss of 3% to 5% produce clinically meaningful health benefits, and greater weight losses produce greater benefits NHLBI Grade: A (Strong) ACC/AHA COR: I; ACC/AHA LOE: A.
a. Sustained weight loss of 3% to 5% is likely to result in clinically meaningful reductions in triglycerides, blood glucose, hemoglobin A1c, and the risk of developing type 2 diabetes.
b. Greater amounts of weight loss will reduce BP, improve low-density lipoprotein cholesterol (LDL-C) and high-density lipoprotein cholesterol (HDL-C), and reduce the need for medications to control BP, blood glucose, and lipids as well as further reduce triglycerides and blood glucose.
Diets for Weight Loss (Dietary Strategies for Weight Loss)
3a. Prescribe a diet to achieve reduced calorie intake for obese or overweight individuals who would benefit from weight loss, as part of a comprehensive lifestyle intervention. Any one of the following methods can be used to reduce food and calorie intake: NHLBI Grade: A (Strong); ACC/AHA COR: I; ACC/AHA LOE: A
a. Prescribe 1,200–1,500 kcal/d for women and 1,500–1,800 kcal/d for men (kilocalorie levels are usually adjusted for the individual's body weight)
b. Prescribe a 500-kcal/d or 750-kcal/d energy deficit or
c. Prescribe one of the evidence-based diets that restricts certain food types (such as high-carbohydrate foods, low-fiber foods, or high-fat foods) in order to create an energy deficit by reduced food intake.
3b. Prescribe a calorie-restricted diet for obese and overweight individuals who would benefit from weight loss, based on the patient's preferences and health status, and preferably refer to a nutrition professional* for counseling. A variety of dietary approaches can produce weight loss in overweight and obese adults, as presented in critical question (CQ) 3, evidence statement (ES) 2. NHLBI Grade: A (Strong); ACC/AHA COR: I; ACC/AHA LOE: A
Lifestyle Intervention and Counseling (Comprehensive Lifestyle Intervention)
4a. Advise overweight and obese individuals who would benefit from weight loss to participate for ≥6 months in a comprehensive lifestyle program that assists participants in adhering to a lower-calorie diet and in increasing physical activity through the use of behavioral strategies. NHLBI Grade: A (Strong); ACC/AHA COR: I; ACC/AHA LOE: A
4b. Prescribe on-site, high-intensity (i.e., ≥14 sessions in 6 mo) comprehensive weight loss interventions provided in individual or group sessions by a trained interventionist.† NHLBI Grade: A (Strong); ACC/AHA COR: I; ACC/AHA LOE: A
4c. Electronically-delivered weight loss programs (including by telephone) that include personalized feedback from a trained interventionist† can be prescribed for weight loss but may result in smaller weight loss than face-to-face interventions. NHLBI Grade: B (Moderate); ACC/AHA COR: IIa; ACC/AHA LOE: A
4d. Some commercial-based programs that provide a comprehensive lifestyle intervention can be prescribed as an option for weight loss, provided there is peer-reviewed published evidence of their safety and efficacy. NHLBI Grade: B (Moderate); ACC/AHA COR: IIa; ACC/AHA LOE: A
4e. Use a very-low-calorie diet (defined as <800 kcal/d) only in limited circumstances and only when provided by trained practitioners in a medical care setting where medical monitoring and high-intensity lifestyle intervention can be provided. Medical supervision is required because of the rapid rate of weight loss and potential for health complications. NHLBI Grade: A (Strong); ACC/AHA COR: IIa‡ ACC/AHA LOE: A
4f. Advise overweight and obese individuals who have lost weight to participate long term (≥1 year) in a comprehensive weight loss maintenance program. NHLBI Grade: A (Strong); ACC/AHA COR: I; ACC/AHA LOE: A
4g. For weight loss maintenance, prescribe face-to-face or telephone-delivered weight loss maintenance programs that provide regular contact (monthly or more frequently) with a trained interventionist† who helps participants engage in high levels of physical activity (i.e., 200–300 min/wk), monitor body weight regularly (i.e., weekly or more frequently), and consume a reduced-calorie diet (needed to maintain lower body weight). NHLBI Grade: A (Strong); ACC/AHA COR: I; ACC/AHA LOE: A
Selecting Patients for Bariatric Surgical Treatment for Obesity (Bariatric Surgical Treatment for Obesity)
5a. Advise adults with a BMI ≥40 kg/m2 or BMI ≥35 kg/m2 with obesity-related comorbid conditions who are motivated to lose weight and who have not responded to behavioral treatment with or without pharmacotherapy with sufficient weight loss to achieve targeted health outcome goals that bariatric surgery may be an appropriate option to improve health and offer referral to an experienced bariatric surgeon for consultation and evaluation. NHLBI Grade: A (Strong); ACC/AHA COR: IIa§; ACC/AHA LOE: A
5b. For individuals with a BMI <35 kg/m2, there is insufficient evidence to recommend for or against undergoing bariatric surgical procedures. NHLBI Grade: N (No Recommendation)
5c. Advise patients that choice of a specific bariatric surgical procedure may be affected by patient factors, including age, severity of obesity/BMI, obesity-related comorbid conditions, other operative risk factors, risk of short- and long-term complications, behavioral and psychosocial factors, and patient tolerance for risk, as well as provider factors (surgeon and facility). NHLBI Grade: E (Expert Opinion); ACC/AHA COR: IIb; ACC/AHA LOE: C
*Nutrition professional: In the studies that form the evidence base for this recommendation, a registered dietitian usually delivered the dietary guidance; in most cases, the intervention was delivered in university nutrition departments or in hospital medical care settings where access to nutrition professionals was available.
†Trained interventionist: In the studies reviewed, trained interventionists included mostly health professionals (e.g., registered dietitians, psychologists, exercise specialists, health counselors, or professionals in training) who adhered to formal protocols in weight management. In a few cases, lay persons were used as trained interventionists; they received instruction in weight management protocols (designed by health professionals) in programs that have been validated in high-quality trials published in peer-reviewed journals.
‡There is strong evidence that if a provider is going to use a very-low-calorie diet, it should be done with high levels of monitoring by experienced personnel; that does not mean that practitioners should prescribe very-low-calorie diets. Because of concern that an ACC/AHA Class I recommendation would be interpreted to mean that the patients should go on a very-low-calorie diet, it was the consensus of the Expert Panel that this maps more closely to an ACC/AHA Class IIa recommendation.
§There is strong evidence that the benefits of surgery outweigh the risks for some patients. These patients can be offered a referral to discuss surgery as an option. This does not mean that all patients who meet the criteria should have surgery. This decision-making process is quite complex and is best performed by experts. The ACC/AHA criterion for a Class I recommendation states that the treatment/procedure should be performed/administered. This recommendation as stated does not meet the criterion that the treatment should be performed. Thus, the ACC/AHA classification criteria do not directly map to the NHLBI grade assigned by the Expert Panel.
Definitions:
NHLBI Grading of the Strength of Recommendations
| Grade | Strength of Recommendation* |
|---|---|
| A | Strong recommendation There is high certainty based on evidence that the net benefit† is substantial. |
| B | Moderate recommendation There is moderate certainty based on evidence that the net benefit is moderate to substantial, or there is high certainty that the net benefit is moderate. |
| C | Weak recommendation There is at least moderate certainty based on evidence that there is a small net benefit. |
| D | Recommendation against There is at least moderate certainty based on evidence that there is no net benefit or that risks/harms outweigh benefits. |
| E | Expert opinion ("There is insufficient evidence or evidence is unclear or conflicting, but this is what the Work Group recommends.") Net benefit is unclear. Balance of benefits and harms cannot be determined because of no evidence, insufficient evidence, unclear evidence, or conflicting evidence, but the Work Group thought it was important to provide clinical guidance and make a recommendation. Further research is recommended in this area. |
| N | No recommendation for or against ("There is insufficient evidence or evidence is unclear or conflicting.") Net benefit is unclear. Balance of benefits and harms cannot be determined because of no evidence, insufficient evidence, unclear evidence, or conflicting evidence, and the Work Group thought no recommendation should be made. Further research is recommended in this area. |
*In most cases, the strength of the recommendation should be closely aligned with the quality of the evidence; however, under some circumstances, there may be valid reasons for making recommendations that are not closely aligned with the quality of the evidence (e.g., strong recommendation when the evidence quality is moderate, such as smoking cessation to reduce cardiovascular disease [CVD] risk or ordering an electrocardiogram [ECG] as part of the initial diagnostic work-up for a patient presenting with possible myocardial infarction [MI]). Those situations should be limited and the rationale explained clearly by the Work Group.
†Net benefit is defined as benefits minus risks/harms of the service/intervention.
NHLBI Quality Rating of the Strength of Evidence
| Type of Evidence | Quality Rating* |
|---|---|
| High |
| Moderate |
| Low |
*In some cases, other evidence, such as large all-or-none case series (e.g., jumping from airplanes or tall structures), can represent high- or moderate-quality evidence. In such cases, the rationale for the evidence rating exception should be explained by the Work Group and clearly justified.
†"Well-designed, well-executed" refers to studies that directly address the question; use adequate randomization, blinding, and allocation concealment; are adequately powered; use intention-to-treat analyses; and have high follow-up rates.
‡Limitations include concerns with the design and execution of a study that result in decreased confidence in the true estimate of the effect. Examples of such limitations include but are not limited to: inadequate randomization, lack of blinding of study participants or outcome assessors, inadequate power, outcomes of interest that are not prespecified for the primary outcomes, low follow-up rates, and findings based on subgroup analyses. Whether the limitations are considered minor or major is based on the number and severity of flaws in design or execution. Rules for determining whether the limitations are considered minor or major and how they will affect rating of the individual studies will be developed collaboratively with the methodology team.
§Nonrandomized controlled studies refer to intervention studies where assignment to intervention and comparison groups is not random (e.g., quasi-experimental study design).
¶Observational studies include prospective and retrospective cohort, case-control, and cross-sectional studies.
Applying Classification of Recommendations and Level of Evidence
| Size of Treatment Effect | |||||||
|---|---|---|---|---|---|---|---|
| CLASS I Benefit >>> Risk Procedure/Treatment SHOULD be performed/ administered | CLASS IIa Benefit >> Risk Additional studies with focused objectives needed IT IS REASONABLE to perform procedure/administer treatment | CLASS IIb Benefit ≥ Risk Additional studies with broad objectives needed; additional registry data would be helpful Procedure/Treatment MAY BE CONSIDERED | CLASS III No Benefit or Class III Harm | ||||
| Procedure/Test | Treatment | ||||||
| COR III: No Benefit | Not helpful | No proven benefit | |||||
| COR III: Harm | Excess cost without benefit or harmful | Harmful to patients | |||||
| Estimate of Certainty (Precision) of Treatment Effect | LEVEL A Multiple populations evaluated* Data derived from multiple randomized clinical trials or meta-analyses |
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| LEVEL B Limited populations evaluated* Data derived from a single randomized trial or nonrandomized studies |
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| LEVEL C Very limited populations evaluated* Only consensus opinion of experts, case studies, or standard of care |
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A recommendation with Level of Evidence B or C does not imply the recommendation is weak. Many important clinical questions addressed in the guidelines do not lend themselves to clinical trials. Even when randomized trials are unavailable, there may be a very clear clinical consensus that a particular test or therapy is useful or effective.
*Data available from clinical trials or registries about the usefulness/efficacy in different subpopulations, such as sex, age, history of diabetes, history of prior myocardial infarction, history of heart failure, and prior aspirin use.
†For comparative-effectiveness recommendations (Class I and IIa; Level of Evidence A and B only), studies that support the use of comparator verbs should involve direct comparisons of the treatments or strategies being evaluated.
Recommendations
Each recommendation has been mapped from the NHLBI grading format to the American College of Cardiology/American Heart Association Class of Recommendation/Level of Evidence (ACC/AHA COR/LOE) construct and is expressed in both formats. Because of the inherent differences in grading systems and the clinical questions driving the recommendations, alignment between the NHLBI and ACC/AHA formats is in some cases imperfect. Definitions for the NHLBI strength of recommendation (A-E, N) and quality of evidence (High, Moderate, Low) and the ACC/AHA levels of the evidence (LOE: A-C) and classes of recommendations (COR: I-III) are provided at the end of the "Major Recommendations" field.
Summary of Recommendations for Obesity
Identifying Patients Who Need to Lose Weight (Body Mass Index [BMI] and Waist Circumference)
1a. Measure height and weight and calculate BMI at annual visits or more frequently. NHLBI Grade: E (Expert Opinion); ACC/AHA COR: I; ACC/AHA LOE: C
1b. Use the current cutpoints for overweight (BMI 25.0–29.9 kg/m2) and obesity (BMI ≥30 kg/m2) to identify adults who may be at elevated risk of cardiovascular disease (CVD) and the current cutpoints for obesity (BMI ≥30 kg/m2) to identify adults who may be at elevated risk of mortality from all causes. NHLBI Grade: A (Strong); ACC/AHA COR: I; ACC/AHA LOE: B
1c. Advise overweight and obese adults that the greater the BMI, the greater the risk of CVD, type 2 diabetes, and all-cause mortality. NHLBI Grade: A (Strong) ACC/AHA COR: I; ACC/AHA LOE: B
1d. Measure waist circumference at annual visits or more frequently in overweight and obese adults. Advise adults that the greater the waist circumference, the greater the risk of CVD, type 2 diabetes, and all-cause mortality. The cutpoints currently in common use (from either National Institutes of Health [NIH]/NHLBI or World Health Organization/International Diabetes Federation [WHO/IDF]) may continue to be used to identify patients who may be at increased risk until further evidence becomes available. NHLBI Grade: E (Expert Opinion); ACC/AHA COR: IIa; ACC/AHA LOE: B
Matching Treatment Benefits with Risk Profiles (Reduction in Body Weight Effect on Risk Factors for CVD, Events, Morbidity and Mortality)
2. Counsel overweight and obese adults with cardiovascular risk factors (high blood pressure [BP], hyperlipidemia, and hyperglycemia) that lifestyle changes that produce even modest, sustained weight loss of 3% to 5% produce clinically meaningful health benefits, and greater weight losses produce greater benefits NHLBI Grade: A (Strong) ACC/AHA COR: I; ACC/AHA LOE: A.
a. Sustained weight loss of 3% to 5% is likely to result in clinically meaningful reductions in triglycerides, blood glucose, hemoglobin A1c, and the risk of developing type 2 diabetes.
b. Greater amounts of weight loss will reduce BP, improve low-density lipoprotein cholesterol (LDL-C) and high-density lipoprotein cholesterol (HDL-C), and reduce the need for medications to control BP, blood glucose, and lipids as well as further reduce triglycerides and blood glucose.
Diets for Weight Loss (Dietary Strategies for Weight Loss)
3a. Prescribe a diet to achieve reduced calorie intake for obese or overweight individuals who would benefit from weight loss, as part of a comprehensive lifestyle intervention. Any one of the following methods can be used to reduce food and calorie intake: NHLBI Grade: A (Strong); ACC/AHA COR: I; ACC/AHA LOE: A
a. Prescribe 1,200–1,500 kcal/d for women and 1,500–1,800 kcal/d for men (kilocalorie levels are usually adjusted for the individual's body weight)
b. Prescribe a 500-kcal/d or 750-kcal/d energy deficit or
c. Prescribe one of the evidence-based diets that restricts certain food types (such as high-carbohydrate foods, low-fiber foods, or high-fat foods) in order to create an energy deficit by reduced food intake.
3b. Prescribe a calorie-restricted diet for obese and overweight individuals who would benefit from weight loss, based on the patient's preferences and health status, and preferably refer to a nutrition professional* for counseling. A variety of dietary approaches can produce weight loss in overweight and obese adults, as presented in critical question (CQ) 3, evidence statement (ES) 2. NHLBI Grade: A (Strong); ACC/AHA COR: I; ACC/AHA LOE: A
Lifestyle Intervention and Counseling (Comprehensive Lifestyle Intervention)
4a. Advise overweight and obese individuals who would benefit from weight loss to participate for ≥6 months in a comprehensive lifestyle program that assists participants in adhering to a lower-calorie diet and in increasing physical activity through the use of behavioral strategies. NHLBI Grade: A (Strong); ACC/AHA COR: I; ACC/AHA LOE: A
4b. Prescribe on-site, high-intensity (i.e., ≥14 sessions in 6 mo) comprehensive weight loss interventions provided in individual or group sessions by a trained interventionist.† NHLBI Grade: A (Strong); ACC/AHA COR: I; ACC/AHA LOE: A
4c. Electronically-delivered weight loss programs (including by telephone) that include personalized feedback from a trained interventionist† can be prescribed for weight loss but may result in smaller weight loss than face-to-face interventions. NHLBI Grade: B (Moderate); ACC/AHA COR: IIa; ACC/AHA LOE: A
4d. Some commercial-based programs that provide a comprehensive lifestyle intervention can be prescribed as an option for weight loss, provided there is peer-reviewed published evidence of their safety and efficacy. NHLBI Grade: B (Moderate); ACC/AHA COR: IIa; ACC/AHA LOE: A
4e. Use a very-low-calorie diet (defined as <800 kcal/d) only in limited circumstances and only when provided by trained practitioners in a medical care setting where medical monitoring and high-intensity lifestyle intervention can be provided. Medical supervision is required because of the rapid rate of weight loss and potential for health complications. NHLBI Grade: A (Strong); ACC/AHA COR: IIa‡ ACC/AHA LOE: A
4f. Advise overweight and obese individuals who have lost weight to participate long term (≥1 year) in a comprehensive weight loss maintenance program. NHLBI Grade: A (Strong); ACC/AHA COR: I; ACC/AHA LOE: A
4g. For weight loss maintenance, prescribe face-to-face or telephone-delivered weight loss maintenance programs that provide regular contact (monthly or more frequently) with a trained interventionist† who helps participants engage in high levels of physical activity (i.e., 200–300 min/wk), monitor body weight regularly (i.e., weekly or more frequently), and consume a reduced-calorie diet (needed to maintain lower body weight). NHLBI Grade: A (Strong); ACC/AHA COR: I; ACC/AHA LOE: A
Selecting Patients for Bariatric Surgical Treatment for Obesity (Bariatric Surgical Treatment for Obesity)
5a. Advise adults with a BMI ≥40 kg/m2 or BMI ≥35 kg/m2 with obesity-related comorbid conditions who are motivated to lose weight and who have not responded to behavioral treatment with or without pharmacotherapy with sufficient weight loss to achieve targeted health outcome goals that bariatric surgery may be an appropriate option to improve health and offer referral to an experienced bariatric surgeon for consultation and evaluation. NHLBI Grade: A (Strong); ACC/AHA COR: IIa§; ACC/AHA LOE: A
5b. For individuals with a BMI <35 kg/m2, there is insufficient evidence to recommend for or against undergoing bariatric surgical procedures. NHLBI Grade: N (No Recommendation)
5c. Advise patients that choice of a specific bariatric surgical procedure may be affected by patient factors, including age, severity of obesity/BMI, obesity-related comorbid conditions, other operative risk factors, risk of short- and long-term complications, behavioral and psychosocial factors, and patient tolerance for risk, as well as provider factors (surgeon and facility). NHLBI Grade: E (Expert Opinion); ACC/AHA COR: IIb; ACC/AHA LOE: C
*Nutrition professional: In the studies that form the evidence base for this recommendation, a registered dietitian usually delivered the dietary guidance; in most cases, the intervention was delivered in university nutrition departments or in hospital medical care settings where access to nutrition professionals was available.
†Trained interventionist: In the studies reviewed, trained interventionists included mostly health professionals (e.g., registered dietitians, psychologists, exercise specialists, health counselors, or professionals in training) who adhered to formal protocols in weight management. In a few cases, lay persons were used as trained interventionists; they received instruction in weight management protocols (designed by health professionals) in programs that have been validated in high-quality trials published in peer-reviewed journals.
‡There is strong evidence that if a provider is going to use a very-low-calorie diet, it should be done with high levels of monitoring by experienced personnel; that does not mean that practitioners should prescribe very-low-calorie diets. Because of concern that an ACC/AHA Class I recommendation would be interpreted to mean that the patients should go on a very-low-calorie diet, it was the consensus of the Expert Panel that this maps more closely to an ACC/AHA Class IIa recommendation.
§There is strong evidence that the benefits of surgery outweigh the risks for some patients. These patients can be offered a referral to discuss surgery as an option. This does not mean that all patients who meet the criteria should have surgery. This decision-making process is quite complex and is best performed by experts. The ACC/AHA criterion for a Class I recommendation states that the treatment/procedure should be performed/administered. This recommendation as stated does not meet the criterion that the treatment should be performed. Thus, the ACC/AHA classification criteria do not directly map to the NHLBI grade assigned by the Expert Panel.
Definitions:
NHLBI Grading of the Strength of Recommendations
| Grade | Strength of Recommendation* |
|---|---|
| A | Strong recommendation There is high certainty based on evidence that the net benefit† is substantial. |
| B | Moderate recommendation There is moderate certainty based on evidence that the net benefit is moderate to substantial, or there is high certainty that the net benefit is moderate. |
| C | Weak recommendation There is at least moderate certainty based on evidence that there is a small net benefit. |
| D | Recommendation against There is at least moderate certainty based on evidence that there is no net benefit or that risks/harms outweigh benefits. |
| E | Expert opinion ("There is insufficient evidence or evidence is unclear or conflicting, but this is what the Work Group recommends.") Net benefit is unclear. Balance of benefits and harms cannot be determined because of no evidence, insufficient evidence, unclear evidence, or conflicting evidence, but the Work Group thought it was important to provide clinical guidance and make a recommendation. Further research is recommended in this area. |
| N | No recommendation for or against ("There is insufficient evidence or evidence is unclear or conflicting.") Net benefit is unclear. Balance of benefits and harms cannot be determined because of no evidence, insufficient evidence, unclear evidence, or conflicting evidence, and the Work Group thought no recommendation should be made. Further research is recommended in this area. |
*In most cases, the strength of the recommendation should be closely aligned with the quality of the evidence; however, under some circumstances, there may be valid reasons for making recommendations that are not closely aligned with the quality of the evidence (e.g., strong recommendation when the evidence quality is moderate, such as smoking cessation to reduce cardiovascular disease [CVD] risk or ordering an electrocardiogram [ECG] as part of the initial diagnostic work-up for a patient presenting with possible myocardial infarction [MI]). Those situations should be limited and the rationale explained clearly by the Work Group.
†Net benefit is defined as benefits minus risks/harms of the service/intervention.
NHLBI Quality Rating of the Strength of Evidence
| Type of Evidence | Quality Rating* |
|---|---|
| High |
| Moderate |
| Low |
*In some cases, other evidence, such as large all-or-none case series (e.g., jumping from airplanes or tall structures), can represent high- or moderate-quality evidence. In such cases, the rationale for the evidence rating exception should be explained by the Work Group and clearly justified.
†"Well-designed, well-executed" refers to studies that directly address the question; use adequate randomization, blinding, and allocation concealment; are adequately powered; use intention-to-treat analyses; and have high follow-up rates.
‡Limitations include concerns with the design and execution of a study that result in decreased confidence in the true estimate of the effect. Examples of such limitations include but are not limited to: inadequate randomization, lack of blinding of study participants or outcome assessors, inadequate power, outcomes of interest that are not prespecified for the primary outcomes, low follow-up rates, and findings based on subgroup analyses. Whether the limitations are considered minor or major is based on the number and severity of flaws in design or execution. Rules for determining whether the limitations are considered minor or major and how they will affect rating of the individual studies will be developed collaboratively with the methodology team.
§Nonrandomized controlled studies refer to intervention studies where assignment to intervention and comparison groups is not random (e.g., quasi-experimental study design).
¶Observational studies include prospective and retrospective cohort, case-control, and cross-sectional studies.
Applying Classification of Recommendations and Level of Evidence
| Size of Treatment Effect | |||||||
|---|---|---|---|---|---|---|---|
| CLASS I Benefit >>> Risk Procedure/Treatment SHOULD be performed/ administered | CLASS IIa Benefit >> Risk Additional studies with focused objectives needed IT IS REASONABLE to perform procedure/administer treatment | CLASS IIb Benefit ≥ Risk Additional studies with broad objectives needed; additional registry data would be helpful Procedure/Treatment MAY BE CONSIDERED | CLASS III No Benefit or Class III Harm | ||||
| Procedure/Test | Treatment | ||||||
| COR III: No Benefit | Not helpful | No proven benefit | |||||
| COR III: Harm | Excess cost without benefit or harmful | Harmful to patients | |||||
| Estimate of Certainty (Precision) of Treatment Effect | LEVEL A Multiple populations evaluated* Data derived from multiple randomized clinical trials or meta-analyses |
|
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| ||
| LEVEL B Limited populations evaluated* Data derived from a single randomized trial or nonrandomized studies |
|
|
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| |||
| LEVEL C Very limited populations evaluated* Only consensus opinion of experts, case studies, or standard of care |
|
|
|
| |||
A recommendation with Level of Evidence B or C does not imply the recommendation is weak. Many important clinical questions addressed in the guidelines do not lend themselves to clinical trials. Even when randomized trials are unavailable, there may be a very clear clinical consensus that a particular test or therapy is useful or effective.
*Data available from clinical trials or registries about the usefulness/efficacy in different subpopulations, such as sex, age, history of diabetes, history of prior myocardial infarction, history of heart failure, and prior aspirin use.
†For comparative-effectiveness recommendations (Class I and IIa; Level of Evidence A and B only), studies that support the use of comparator verbs should involve direct comparisons of the treatments or strategies being evaluated.
Recommendations
Each recommendation has been mapped from the NHLBI grading format to the American College of Cardiology/American Heart Association Class of Recommendation/Level of Evidence (ACC/AHA COR/LOE) construct and is expressed in both formats. Because of the inherent differences in grading systems and the clinical questions driving the recommendations, alignment between the NHLBI and ACC/AHA formats is in some cases imperfect. Definitions for the NHLBI strength of recommendation (A-E, N) and quality of evidence (High, Moderate, Low) and the ACC/AHA levels of the evidence (LOE: A-C) and classes of recommendations (COR: I-III) are provided at the end of the "Major Recommendations" field.
Summary of Recommendations for Obesity
Identifying Patients Who Need to Lose Weight (Body Mass Index [BMI] and Waist Circumference)
1a. Measure height and weight and calculate BMI at annual visits or more frequently. NHLBI Grade: E (Expert Opinion); ACC/AHA COR: I; ACC/AHA LOE: C
1b. Use the current cutpoints for overweight (BMI 25.0–29.9 kg/m2) and obesity (BMI ≥30 kg/m2) to identify adults who may be at elevated risk of cardiovascular disease (CVD) and the current cutpoints for obesity (BMI ≥30 kg/m2) to identify adults who may be at elevated risk of mortality from all causes. NHLBI Grade: A (Strong); ACC/AHA COR: I; ACC/AHA LOE: B
1c. Advise overweight and obese adults that the greater the BMI, the greater the risk of CVD, type 2 diabetes, and all-cause mortality. NHLBI Grade: A (Strong) ACC/AHA COR: I; ACC/AHA LOE: B
1d. Measure waist circumference at annual visits or more frequently in overweight and obese adults. Advise adults that the greater the waist circumference, the greater the risk of CVD, type 2 diabetes, and all-cause mortality. The cutpoints currently in common use (from either National Institutes of Health [NIH]/NHLBI or World Health Organization/International Diabetes Federation [WHO/IDF]) may continue to be used to identify patients who may be at increased risk until further evidence becomes available. NHLBI Grade: E (Expert Opinion); ACC/AHA COR: IIa; ACC/AHA LOE: B
Matching Treatment Benefits with Risk Profiles (Reduction in Body Weight Effect on Risk Factors for CVD, Events, Morbidity and Mortality)
2. Counsel overweight and obese adults with cardiovascular risk factors (high blood pressure [BP], hyperlipidemia, and hyperglycemia) that lifestyle changes that produce even modest, sustained weight loss of 3% to 5% produce clinically meaningful health benefits, and greater weight losses produce greater benefits NHLBI Grade: A (Strong) ACC/AHA COR: I; ACC/AHA LOE: A.
a. Sustained weight loss of 3% to 5% is likely to result in clinically meaningful reductions in triglycerides, blood glucose, hemoglobin A1c, and the risk of developing type 2 diabetes.
b. Greater amounts of weight loss will reduce BP, improve low-density lipoprotein cholesterol (LDL-C) and high-density lipoprotein cholesterol (HDL-C), and reduce the need for medications to control BP, blood glucose, and lipids as well as further reduce triglycerides and blood glucose.
Diets for Weight Loss (Dietary Strategies for Weight Loss)
3a. Prescribe a diet to achieve reduced calorie intake for obese or overweight individuals who would benefit from weight loss, as part of a comprehensive lifestyle intervention. Any one of the following methods can be used to reduce food and calorie intake: NHLBI Grade: A (Strong); ACC/AHA COR: I; ACC/AHA LOE: A
a. Prescribe 1,200–1,500 kcal/d for women and 1,500–1,800 kcal/d for men (kilocalorie levels are usually adjusted for the individual's body weight)
b. Prescribe a 500-kcal/d or 750-kcal/d energy deficit or
c. Prescribe one of the evidence-based diets that restricts certain food types (such as high-carbohydrate foods, low-fiber foods, or high-fat foods) in order to create an energy deficit by reduced food intake.
3b. Prescribe a calorie-restricted diet for obese and overweight individuals who would benefit from weight loss, based on the patient's preferences and health status, and preferably refer to a nutrition professional* for counseling. A variety of dietary approaches can produce weight loss in overweight and obese adults, as presented in critical question (CQ) 3, evidence statement (ES) 2. NHLBI Grade: A (Strong); ACC/AHA COR: I; ACC/AHA LOE: A
Lifestyle Intervention and Counseling (Comprehensive Lifestyle Intervention)
4a. Advise overweight and obese individuals who would benefit from weight loss to participate for ≥6 months in a comprehensive lifestyle program that assists participants in adhering to a lower-calorie diet and in increasing physical activity through the use of behavioral strategies. NHLBI Grade: A (Strong); ACC/AHA COR: I; ACC/AHA LOE: A
4b. Prescribe on-site, high-intensity (i.e., ≥14 sessions in 6 mo) comprehensive weight loss interventions provided in individual or group sessions by a trained interventionist.† NHLBI Grade: A (Strong); ACC/AHA COR: I; ACC/AHA LOE: A
4c. Electronically-delivered weight loss programs (including by telephone) that include personalized feedback from a trained interventionist† can be prescribed for weight loss but may result in smaller weight loss than face-to-face interventions. NHLBI Grade: B (Moderate); ACC/AHA COR: IIa; ACC/AHA LOE: A
4d. Some commercial-based programs that provide a comprehensive lifestyle intervention can be prescribed as an option for weight loss, provided there is peer-reviewed published evidence of their safety and efficacy. NHLBI Grade: B (Moderate); ACC/AHA COR: IIa; ACC/AHA LOE: A
4e. Use a very-low-calorie diet (defined as <800 kcal/d) only in limited circumstances and only when provided by trained practitioners in a medical care setting where medical monitoring and high-intensity lifestyle intervention can be provided. Medical supervision is required because of the rapid rate of weight loss and potential for health complications. NHLBI Grade: A (Strong); ACC/AHA COR: IIa‡ ACC/AHA LOE: A
4f. Advise overweight and obese individuals who have lost weight to participate long term (≥1 year) in a comprehensive weight loss maintenance program. NHLBI Grade: A (Strong); ACC/AHA COR: I; ACC/AHA LOE: A
4g. For weight loss maintenance, prescribe face-to-face or telephone-delivered weight loss maintenance programs that provide regular contact (monthly or more frequently) with a trained interventionist† who helps participants engage in high levels of physical activity (i.e., 200–300 min/wk), monitor body weight regularly (i.e., weekly or more frequently), and consume a reduced-calorie diet (needed to maintain lower body weight). NHLBI Grade: A (Strong); ACC/AHA COR: I; ACC/AHA LOE: A
Selecting Patients for Bariatric Surgical Treatment for Obesity (Bariatric Surgical Treatment for Obesity)
5a. Advise adults with a BMI ≥40 kg/m2 or BMI ≥35 kg/m2 with obesity-related comorbid conditions who are motivated to lose weight and who have not responded to behavioral treatment with or without pharmacotherapy with sufficient weight loss to achieve targeted health outcome goals that bariatric surgery may be an appropriate option to improve health and offer referral to an experienced bariatric surgeon for consultation and evaluation. NHLBI Grade: A (Strong); ACC/AHA COR: IIa§; ACC/AHA LOE: A
5b. For individuals with a BMI <35 kg/m2, there is insufficient evidence to recommend for or against undergoing bariatric surgical procedures. NHLBI Grade: N (No Recommendation)
5c. Advise patients that choice of a specific bariatric surgical procedure may be affected by patient factors, including age, severity of obesity/BMI, obesity-related comorbid conditions, other operative risk factors, risk of short- and long-term complications, behavioral and psychosocial factors, and patient tolerance for risk, as well as provider factors (surgeon and facility). NHLBI Grade: E (Expert Opinion); ACC/AHA COR: IIb; ACC/AHA LOE: C
*Nutrition professional: In the studies that form the evidence base for this recommendation, a registered dietitian usually delivered the dietary guidance; in most cases, the intervention was delivered in university nutrition departments or in hospital medical care settings where access to nutrition professionals was available.
†Trained interventionist: In the studies reviewed, trained interventionists included mostly health professionals (e.g., registered dietitians, psychologists, exercise specialists, health counselors, or professionals in training) who adhered to formal protocols in weight management. In a few cases, lay persons were used as trained interventionists; they received instruction in weight management protocols (designed by health professionals) in programs that have been validated in high-quality trials published in peer-reviewed journals.
‡There is strong evidence that if a provider is going to use a very-low-calorie diet, it should be done with high levels of monitoring by experienced personnel; that does not mean that practitioners should prescribe very-low-calorie diets. Because of concern that an ACC/AHA Class I recommendation would be interpreted to mean that the patients should go on a very-low-calorie diet, it was the consensus of the Expert Panel that this maps more closely to an ACC/AHA Class IIa recommendation.
§There is strong evidence that the benefits of surgery outweigh the risks for some patients. These patients can be offered a referral to discuss surgery as an option. This does not mean that all patients who meet the criteria should have surgery. This decision-making process is quite complex and is best performed by experts. The ACC/AHA criterion for a Class I recommendation states that the treatment/procedure should be performed/administered. This recommendation as stated does not meet the criterion that the treatment should be performed. Thus, the ACC/AHA classification criteria do not directly map to the NHLBI grade assigned by the Expert Panel.
Definitions:
NHLBI Grading of the Strength of Recommendations
| Grade | Strength of Recommendation* |
|---|---|
| A | Strong recommendation There is high certainty based on evidence that the net benefit† is substantial. |
| B | Moderate recommendation There is moderate certainty based on evidence that the net benefit is moderate to substantial, or there is high certainty that the net benefit is moderate. |
| C | Weak recommendation There is at least moderate certainty based on evidence that there is a small net benefit. |
| D | Recommendation against There is at least moderate certainty based on evidence that there is no net benefit or that risks/harms outweigh benefits. |
| E | Expert opinion ("There is insufficient evidence or evidence is unclear or conflicting, but this is what the Work Group recommends.") Net benefit is unclear. Balance of benefits and harms cannot be determined because of no evidence, insufficient evidence, unclear evidence, or conflicting evidence, but the Work Group thought it was important to provide clinical guidance and make a recommendation. Further research is recommended in this area. |
| N | No recommendation for or against ("There is insufficient evidence or evidence is unclear or conflicting.") Net benefit is unclear. Balance of benefits and harms cannot be determined because of no evidence, insufficient evidence, unclear evidence, or conflicting evidence, and the Work Group thought no recommendation should be made. Further research is recommended in this area. |
*In most cases, the strength of the recommendation should be closely aligned with the quality of the evidence; however, under some circumstances, there may be valid reasons for making recommendations that are not closely aligned with the quality of the evidence (e.g., strong recommendation when the evidence quality is moderate, such as smoking cessation to reduce cardiovascular disease [CVD] risk or ordering an electrocardiogram [ECG] as part of the initial diagnostic work-up for a patient presenting with possible myocardial infarction [MI]). Those situations should be limited and the rationale explained clearly by the Work Group.
†Net benefit is defined as benefits minus risks/harms of the service/intervention.
NHLBI Quality Rating of the Strength of Evidence
| Type of Evidence | Quality Rating* |
|---|---|
| High |
| Moderate |
| Low |
*In some cases, other evidence, such as large all-or-none case series (e.g., jumping from airplanes or tall structures), can represent high- or moderate-quality evidence. In such cases, the rationale for the evidence rating exception should be explained by the Work Group and clearly justified.
†"Well-designed, well-executed" refers to studies that directly address the question; use adequate randomization, blinding, and allocation concealment; are adequately powered; use intention-to-treat analyses; and have high follow-up rates.
‡Limitations include concerns with the design and execution of a study that result in decreased confidence in the true estimate of the effect. Examples of such limitations include but are not limited to: inadequate randomization, lack of blinding of study participants or outcome assessors, inadequate power, outcomes of interest that are not prespecified for the primary outcomes, low follow-up rates, and findings based on subgroup analyses. Whether the limitations are considered minor or major is based on the number and severity of flaws in design or execution. Rules for determining whether the limitations are considered minor or major and how they will affect rating of the individual studies will be developed collaboratively with the methodology team.
§Nonrandomized controlled studies refer to intervention studies where assignment to intervention and comparison groups is not random (e.g., quasi-experimental study design).
¶Observational studies include prospective and retrospective cohort, case-control, and cross-sectional studies.
Applying Classification of Recommendations and Level of Evidence
| Size of Treatment Effect | |||||||
|---|---|---|---|---|---|---|---|
| CLASS I Benefit >>> Risk Procedure/Treatment SHOULD be performed/ administered | CLASS IIa Benefit >> Risk Additional studies with focused objectives needed IT IS REASONABLE to perform procedure/administer treatment | CLASS IIb Benefit ≥ Risk Additional studies with broad objectives needed; additional registry data would be helpful Procedure/Treatment MAY BE CONSIDERED | CLASS III No Benefit or Class III Harm | ||||
| Procedure/Test | Treatment | ||||||
| COR III: No Benefit | Not helpful | No proven benefit | |||||
| COR III: Harm | Excess cost without benefit or harmful | Harmful to patients | |||||
| Estimate of Certainty (Precision) of Treatment Effect | LEVEL A Multiple populations evaluated* Data derived from multiple randomized clinical trials or meta-analyses |
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| LEVEL B Limited populations evaluated* Data derived from a single randomized trial or nonrandomized studies |
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| LEVEL C Very limited populations evaluated* Only consensus opinion of experts, case studies, or standard of care |
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A recommendation with Level of Evidence B or C does not imply the recommendation is weak. Many important clinical questions addressed in the guidelines do not lend themselves to clinical trials. Even when randomized trials are unavailable, there may be a very clear clinical consensus that a particular test or therapy is useful or effective.
*Data available from clinical trials or registries about the usefulness/efficacy in different subpopulations, such as sex, age, history of diabetes, history of prior myocardial infarction, history of heart failure, and prior aspirin use.
†For comparative-effectiveness recommendations (Class I and IIa; Level of Evidence A and B only), studies that support the use of comparator verbs should involve direct comparisons of the treatments or strategies being evaluated.
OBJECTIVE: To develop clinical practice guidelines for management of overweight and obesity in adults.
Guidelines are copyright © 2014 American College of Cardiology/American Heart Association/Obesity Society. All rights reserved. The summary is provided by the Agency for Healthcare Research and Quality.