USPSTF Issues New Recommendations for Obese Kids and Teens

Pam Harrison

June 20, 2017

Physicians should screen children and adolescents 6 years of age and older, and if they are obese, they should refer them for a behavioral intervention program of at least 26 hours' duration to ensure weight loss, the US Preventive Services Task Force (USPSTF) now advises.

The new recommendations update earlier USPSTF guidance on screening for obesity in children 6 years of age and older issued in 2010.

"Obesity can have short-term effects on the health of children and adolescents," write the USPSTF authors. "In addition, obesity in childhood and adolescence often leads to obesity in adulthood, which leads to poor health outcomes," they note.

"The USPSTF concludes with moderate certainty that the net benefit of screening for obesity in children and adolescents 6 years and older and offering or referring them to comprehensive, intensive behavioral interventions to promote improvements in weight status is moderate," the guideline authors conclude.

The new guidance was published in the June 20, 2017 issue of the Journal of the American Medical Association.

The recommended test with which to screen children and adolescents for obesity is the body mass index (BMI). Since height and weight are routinely measured during scheduled office visits, the USPSTF does not stipulate how often youngsters should be screened specifically for obesity.

However, children and adolescents are obese when their BMI places them in the 95th percentile or greater for their age and gender. The USPSTF found that behavioral interventions that expose participants to 26 hours or more of a given program are consistently associated with successful weight loss for up to 12 months and are not associated with harm.

On the other hand, evidence supporting less intensive interventions is not robust and programs that do not expose participants to at least 26 hours of contact are not therefore recommended. The type of interventions advocated for weight loss often involve many different components, but whatever form they take, sessions typically counsel participants about nutrition and exercise.

They may also teach participants how to read food labels to support healthy eating habits. Successful behavioral interventions also try to encourage participants to restrict access to favored foods and to limit screen time, set goals, and solve problems pertaining to healthy eating and exercise.

Comprehensive behavioral interventions lasting longer than this, involving 52 or more contact hours, will need a referral from physicians, who clearly cannot provide such a program in a primary-care setting, the USPSTF authors point out.

As for either metformin or orlistat, the USPSTF members conclude that both medications were associated with weight loss in adolescents but the amount of weight loss attributed to these medications was very small.

They thus conclude that the clinical significance of medication-induced weight loss remains "unclear."

Practically Speaking, Access to Weight-Loss Interventions Is Limited

A number of separate editorials accompany the published recommendations and comment on the background evidence supporting them.

Jason Block, MD, MPH, and Emily Oken, MD, MPH, both from Harvard Medical School and the Harvard Pilgrim Health Care Institute, in Boston, Massachusetts, find fault with the main USPSTF recommendation to refer obese children and adolescents to a comprehensive, intensive behavioral intervention for weight loss.

"Most children with obesity do not have access to the intensive multicomponent behavioral treatments recommended by the USPSTF," they point out. "[And] absent or inadequate insurance coverage is a major barrier to care," they add. Even if families can afford a comprehensive intervention, treatment programs are usually found only in urban centers, limiting access for children and adolescents who live outside these centers.

"Sustained advocacy, innovative means of improving access such as telehealth programs, and enhanced focus on training healthcare professionals in multiple care roles are critical to moving this evidence into action," Drs Block and Oken conclude.

In another editorial, Rachel Thornton, MD, PhD, of Johns Hopkins School of Medicine, Baltimore, Maryland, and colleagues agree that intensive interventions as recommended by the USPSTF are "impractical" for many families.

They also stress that reimbursement is a major obstacle for most patients to access such programs. "At best, implementing the USPSTF recommendation will have modest effects on obesity prevalence in the United States," Dr Thornton and colleagues argue.

Furthermore, they point out that this particular recommendation will likely divert resources from much-needed population-based approaches to prevent obesity in children and adolescents in the first place.

"The approach to childhood obesity must go beyond the clinician's office," Dr Thornton argues.

Policy makers need to take into consideration the multiple factors that make up the "social determinants of health" and that deeply affect how children evolve into healthy adults. "The USPSTF recommendation should provide an impetus to redouble efforts to invest in practice, community, policy, and multilevel intervention research focused on achieving primary prevention and sustained improvements in health and health trajectories for children and adolescents and their families," she and her colleagues write.

"Such a focus is critical for reversing the obesity epidemic," they conclude.

A Patient Page condensing the USPSTF recommendations was also published in the same online issue of JAMA and is available here.

None of the authors had any relevant financial relationships.

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JAMA. 2017;317:2417-2426, 2427-2444, 2378-2380, published online June 20, 2017. Article, Block et al editorial, Thornton et al editorial

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