Preventive Care and Screening Body Mass Index (BMI) Screening and Follow Up Plan

“Obesity is a chronic, multifactorial disease with complex psychological, environmental (social and cultural), genetic, physiologic, metabolic, and behavioral causes and consequences. The prevalence of overweight and obese people is increasing worldwide at an alarming rate in both developing and developed countries. Environmental and behavioral changes brought about by economic development, modernization, and urbanization have been linked to the rise in global obesity. The health consequences are becoming apparent” (Fitch et al., 2013).

More than a third of United States (U.S.) adults have a body mass index (BMI) >= 30 kg/m2 and are at increased risk for diabetes, cardiovascular disease (CVD), and obstructive sleep apnea (Flegal et al., 2012; Ogden et al., 2015; Dong et al., 2020). Hales et al. (2017) reported that the prevalence of obesity among adults and youth in the U.S. was 39.8 percent and 18.5 percent, respectively, from 2015-2016. Furthermore, the prevalence of obesity in adults increased to 42.4 percent in 2018, with the highest percentage among adults in the 40-59 age bracket compared with other age groups (Hales et al., 2020). Hales et al. (2020) also disaggregated the data according to race/ethnicity and noted that obesity prevalence was higher among non-Hispanic Black adults and Hispanic adults when compared with other races and ethnicities. Obesity prevalence was lowest among non-Hispanic Asian men and women. Among males, obesity prevalence was higher among Hispanic males compared with non-Hispanic Black males and non-Hispanic White males. Among females, the prevalence among non-Hispanic Black females was 56.9 percent, which was higher than all other races/ethnicities. In general, the prevalence of obesity in the U.S. remains higher than the Healthy People 2020 goal of 30.5 percent among adults (Hales et al., 2020).

BMI continues to be a common and reasonably reliable measurement to identify overweight and obese adults who may be at an increased risk for future morbidity. Although good quality evidence supports obtaining a BMI, it is important to recognize it is not a perfect measurement. For example, BMI and its associated disease and mortality risk appear to vary among ethnic subgroups. Black/African Americans appear to have the lowest mortality risk at a BMI of 26.2-28.5 kg/m2 in Black women and 27.1-30.2 kg/m2 in Black men. In contrast, Asian populations may experience the lowest mortality rates, starting at a BMI of 23 to 24 kg/m2. The correlation between BMI and diabetes risk also varies by ethnicity (LeBlanc et al., 2011). BMI is not a direct measure of adiposity; consequently, it can over or underestimate adiposity. However, overall, BMI is a derived value that correlates well with total body fat and markers of secondary complications, e.g., hypertension and dyslipidemia (Barlow & the Expert Committee, 2007).

It is important to enhance beneficiary access to appropriate treatments for obesity, which could result in decreased healthcare costs and lower obesity rates. Behavioral weight management treatment has been identified as an effective first-line treatment for obesity, with an average initial weight loss of 8-10 percent. This percentage of weight loss is associated with a significant risk reduction for diabetes and CVD (Wadden, Butryn & Wilson, 2007). Evidence also shows that when provided 14 or more high-intensity behavioral intervention sessions of face-to-face individual or group treatment across 6 months, participants lose up to 8 percent of their weight during that time and experience improvements in heart disease risk factors and quality of life (Wadden, Tronieri, & Butryn, 2020). There is also evidence that high-intensity behavioral counseling is effective, whether delivered in-person, by phone, or electronically (Tronieri et al., 2019). Moreover, intensive behavioral therapy for obesity provided by registered dietitian nutritionists for 6-12 months shows a significant mean weight loss of up to 10 percent of body weight, maintained over one year’s time (Raynor & Champagne, 2016). Despite the evidence that supports weight management counseling, the rate of use in primary care for patients with obesity decreased by 10 percent from 39.9 percent in 1995-1996 to 29.9 percent in 2007-2008 (Kraschnewski et al., 2013). Weight management counseling during primary care visits further declined from 33 percent to 21 percent between 2008-2009 and 2012-2013. This suggests that obesity management in primary care remains suboptimal (Fitzpatrick & Stevens, 2017).

Therefore, screening for BMI and follow-up is critical and will help in reaching the quality goals of population health and cost reduction. However, due to concerns for other underlying conditions (such as bone health) or nutrition-related deficiencies, providers are cautioned to use their best clinical judgment when considering weight management programs for overweight patients, especially the elderly (National Heart, Lung, and Blood Institute [NHLBI] Obesity Education Initiative, 1998).

BMI Below Normal Parameters

On the other end of the body weight spectrum is underweight (BMI < 18.5 kg/m2), which is also detrimental to population health. When compared to normal-weight individuals (BMI 18.5-25 kg/m2), underweight individuals have significantly higher death rates with a Hazard Ratio of 2.27 and 95 percent confidence intervals = 1.78, 2.90 (Borrell & Samuel, 2014). Individuals with a BMI < 18.5 kg/m2 have been shown to be at a higher risk for adverse events, postoperative infection, and/or mortality following a surgical procedure (Katakam et al., 2021; Ottesen et al., 2020; Ottesen et al., 2022; Rudasill et al., 2021). BMI below normal parameters is a risk factor for developing severe illness from respiratory infections such as influenza and COVID-19 (Moser et al., 2019; Ye et al., 2021). BMI below normal parameters can negatively impact both male and female fertility (Boutari et al., 2020; Guo et al., 2019).

Poor nutrition or underlying health conditions can result in underweight (Fryar & Ogden, 2012). The National Health and Nutrition Examination Survey (NHANES) results from 2007-2010 indicate that women are more likely to be underweight than men (Fryar & Ogden, 2012). However, all patients should be equally screened for underweight and followed up with nutritional counseling or another clinically appropriate intervention to reduce mortality and morbidity associated with underweight.

Overweight and Underweight Categories:

Underweight < 18.5; Normal weight 18.5-24.9; Overweight 25-29.9; Obese class I 30-34.9; Obese class II 35-39.9; Obese class III >= 40 (Garvey et al., 2016).

BMI cutoff point value of >= 23 kg/m2 should be used in the screening and confirmation of excess adiposity in Asian adults (Garvey et al., 2016) (Grade B).

Lifestyle/behavioral therapy for overweight and obesity should include behavioral interventions that enhance adherence to prescriptions for a reduced-calorie meal plan and increased physical activity (behavioral interventions can include: self-monitoring of weight, food intake, and physical activity; clear and reasonable goal-setting; education pertaining to obesity, nutrition, and physical activity; face-to-face and group meetings; stimulus control; systematic approaches for problem-solving; stress reduction; cognitive restructuring [i.e., cognitive behavioral therapy], motivational interviewing; behavioral contracting; psychological counseling; and mobilization of social support structures) (Garvey et al., 2016) (Grade A).

Behavioral lifestyle intervention should be tailored to a patient’s ethnic, cultural, socioeconomic, and educational background (Garvey et al., 2016) (Grade B).

The U.S. Preventive Services Task Force (USPSTF) recommends that clinicians offer or refer adults with a BMI of 30 kg/m2 or higher to intensive, multicomponent behavioral interventions (USPSTF, 2018) (Grade B).

Interventions:

– Effective intensive behavioral interventions were designed to help participants achieve or maintain weight loss of at least five percent through a combination of dietary changes and increased physical activity

– Most interventions lasted for one to two years, and the majority had at least 12 sessions in the first year

– Most behavioral interventions focused on problem-solving to identify barriers, self-monitoring of weight, peer support, and relapse prevention

– Interventions also provided tools to support weight loss or weight loss maintenance (e.g., pedometers, food scales, or exercise videos) (USPSTF, 2018)

Nutritional safety for the elderly should be considered when recommending weight reduction. “A clinical decision to forego obesity treatment in older adults should be guided by an evaluation of the potential benefits of weight reduction for day-to-day functioning and reduction of the risk of future cardiovascular events, as well as the patient’s motivation for weight reduction. Care must be taken to ensure that any weight reduction program minimizes the likelihood of adverse effects on bone health or other aspects of nutritional status” (NHLBI Obesity Education Initiative, 1998) (Evidence Category D). In addition, weight reduction prescriptions in older persons should be accompanied by proper nutritional counseling and regular body weight monitoring (NHLBI Obesity Education Initiative, 1998).

The possibility that a standard approach to weight loss will work differently in diverse patient populations must be considered when setting expectations about treatment outcomes (NHLBI Obesity Education Initiative, 1998) (Evidence Category B).

BMI – Body mass index (BMI) is a number calculated using the Quetelet index: weight divided by height squared (W/H2) and is commonly used to classify weight categories. BMI can be calculated using:

Metric Units: BMI = Weight (kg) / (Height (m) x Height (m))

OR

English Units: BMI = Weight (lbs) / (Height (in) x Height (in)) x 703

Follow-Up Plan – Proposed outline of treatment to be conducted as a result of a BMI outside of normal parameters. A follow-up plan may include but is not limited to, documentation of education, referral (for example, to a registered dietitian nutritionist, occupational therapist, physical therapist, primary care provider, exercise physiologist, mental health professional, or surgeon) for lifestyle/behavioral therapy, pharmacological interventions, dietary supplements, exercise counseling, and/or nutrition counseling.

This measure may be reported by eligible clinicians who perform the quality actions described in the measure based on the services provided at the time of the qualifying encounter or during the measurement period and the measure-specific denominator coding.

Telehealth encounters are not eligible for this measure because the measure requires a clinical action that cannot be conducted via telehealth.

BMI Measurement Guidance:

– Height and Weight – An eligible clinician or their staff is required to measure both height and weight. Both height and weight must be measured during the measurement period. Self-reported values cannot be used.

– The BMI may be documented in the provider’s medical record or outside medical records obtained by the provider.

– If the documented BMI is outside of normal parameters, then a follow-up plan is documented during the encounter or measurement period.

– If more than one BMI is reported during the measurement period, and any of the documented BMI assessments is outside of normal parameters, documentation of an appropriate follow-up plan will be used to determine if performance has been met.

– Review the exclusions and exceptions criteria to determine those patients that BMI measurement may not be appropriate or necessary.

Follow-Up Plan Guidance:

The documented follow-up plan must be based on the documented BMI, outside of normal parameters, for example: “Patient referred to nutrition counseling for BMI above or below normal parameters.” See the Definition section for examples of follow-up plan treatments.

Variation has been noted in studies exploring optimal BMI ranges for the elderly (see Donini et al., 2012; Holme & Tonstad, 2015; Diehr et al., 2008). Notably, however, all these studies have arrived at ranges that differ from the standard range for ages 18 and older, which is >= 18.5 and < 25 kg/m2. For instance, both Donini et al. and Holme and Tonstad reported findings that suggest that a higher BMI (higher than the upper end of 25 kg/m2) in the elderly may be beneficial. Similarly, worse outcomes have been associated with being underweight (at a threshold higher than 18.5 kg/m2) at age 65 (Diehr et al., 2008). Because of optimal BMI range variation recommendations from these studies, no specific optimal BMI range for the elderly is used. However, exempting certain patients from a follow-up plan may be appropriate by applying the exception criteria. See Denominator Exception section for examples.

Denominator Exception Guidance:

If a patient meets exception criteria for the denominator (i.e., the patient refuses height or weight measurement or has a documented medical reason for not documenting BMI or a follow-up plan), an eligible clinician must document those criteria on the same day as the qualifying encounter.

This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM.

Patients receiving palliative or hospice care at any time during the measurement period.

Patients who refuse measurement of height and/or weight.