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

Measure Specification

BMI Above Normal Parameters “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 (1).” More than a third of 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 (2,3, 4). Hales reported that the prevalence of obesity among adults and youth in the United States 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 (5). Hales 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 men, obesity prevalence was higher among Hispanic men compared with non-Hispanic Black men and non-Hispanic White men. Obesity prevalence was higher among Hispanic men compared with non-Hispanic Black men. Among women, the prevalence among non-Hispanic Black women was 56.9 percent, which was higher than all other race/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 (6). 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 lowest mortality rates starting at a BMI of 23 to 24 kg/m2. The correlation between BMI and diabetes risk also varies by ethnicity (7).

Moreover, BMI is not a direct measure of adiposity and as a consequence, 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 (8). Furthermore, 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 (9). 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 (10).

There is also evidence that high-intensity behavioral counseling is effective, whether delivered in-person, by phone, or electronically (11). Moreover, Intensive Behavioral Therapy (IBT) for obesity provided by Registered Dietitian Nutritionists for 6-12 months shows significant mean weight loss of up to 10 percent of body weight, maintained over one year’s time (12).

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 (13). 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 (14).

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 and when considering weight management programs for overweight patients, especially the elderly (15).

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 (CI) = 1.

78, 2.90 (16). Individuals with a BMI < 18.5kg/m2 have been shown to be at a higher risk for adverse events, postoperative infection, and/or mortality following a surgical procedure (17, 18, 19, 20). BMI below normal parameters is a risk factor for developing severe illness from respiratory infections such as influenza and COVID- 19 (21, 22). BMI below normal parameters can negatively impact both male and female fertility (23, 24).

Poor nutrition or underlying health conditions can result in underweight (25). The National Health and Nutrition Examination Survey (NHANES) results from 2007-2010 indicate that women are more likely to be underweight than men (25). 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.

All adults should be screened annually using a BMI measurement. BMI measurements ≥ 25kg/m2 should be used to initiate further evaluation of overweight or obesity after taking into account age, gender, ethnicity, fluid status, and muscularity; therefore, clinical evaluation and judgment must be used when BMI is employed as the anthropometric indicator of excess adiposity, particularly in athletes and those with sarcopenia (26) (Grade A).

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 (26). BMI cutoff point value of ≥ 23 kg/m2 should be used in the screening and confirmation of excess adiposity in Asian adults (26) (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) (26) (Grade A). Behavioral lifestyle intervention should be tailored to a patient’s ethnic, cultural, socioeconomic, and educational background (26) (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.

Interventions: • Effective intensive behavioral interventions were designed to help participants achieve or maintain a 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) (Grade B) (27) 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” (15) (Evidence Category D). In addition, weight reduction prescriptions in older persons should be accompanied by proper nutritional counseling and regular body weight monitoring (15). 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 (15) (Evidence Category B).

This measure contains one strata defined by a single submission criteria. This measure produces a single performance rate. For the purposes of MIPS implementation, this patient-intermediate measure is submitted a minimum of once per patient for the performance period. The most recent numerator option/quality data code will be used if the measure is submitted more than once.

There is no diagnosis associated with this measure. The BMI may be documented in the medical record of the provider or in outside medical records obtained by the provider. If the most recent documented BMI is outside of normal parameters, then a follow-up plan is documented during the encounter or during the previous twelve months of the current encounter.

The documented follow-up plan must be based on the most recent documented BMI outside of normal parameters, example: “Patient referred to nutrition counseling for BMI above or below normal parameters” (See Definitions for examples of follow-up plan treatments). If more than one BMI is submitted during the measurement period, the most recent BMI will be used to determine if the performance has been met.

Review the exclusions and exceptions criteria to determine those patients that BMI measurement may not be appropriate or necessary. This measure specification is only available for MIPS Value Pathway (MVP) reporting and is not available for traditional MIPS reporting.