Perspective

USPSTF recommends screening for obesity in children, adolescents

The U.S. Preventive Services Task Force recommends that clinicians screen for obesity in children and adolescents aged at least 6 years and offer or refer them to comprehensive, intensive behavioral interventions to promote improvements in weight status, according to a report recently published in JAMA.

The task force gave such practices a B grade statement.

“Lifestyle-based weight-loss interventions with 26 or more hours of intervention contact are likely to help reduce excess weight in children and adolescents,” Elizabeth A. O’Connor, PhD, from Kaiser Permanente Research Center for Health Research, and colleagues wrote. “The clinical significance of the small benefit of medication use is unclear.”

The USPSTF cited data from the CDC that indicated about 17% of children and adolescents aged 2 to 19 years in the United States have obesity, and nearly 32% of children and adolescents have obesity or are overweight.

According to a press release, this recommendation is “largely consistent” with the 2016 draft recommendation USPSTF issued on this subject, but now contains the word adolescents to further clarify the population to which the recommendation applies.

In 2007, an AMA committee recommended that clinicians’ assessments include BMI calculation as behavioral and medical risk factors for obesity. The AAP agreed with those recommendations and recommended plotting BMI on a growth chart on a yearly basis for all patients aged at least 2 years, researchers stated.

In separate recommendations, the USPSTF also indicated it concluded separately that there is insufficient evidence to assess the balance of benefits and harms of screening for primary hypertension in asymptomatic children and adolescents to prevent subsequent CVD in childhood or adulthood, and insufficient evidence to assess the balance of benefits and harms of screening for lipid disorders in children and adolescents. Both of these recommendations received an I grade.

In an editorial related to the 26 hours of behavioral intervention the USPSTF recommended to treat childhood obesity, Rachel L.J. Thornton, MD, PhD, of the department of pediatrics at Johns Hopkins School of Medicine, and colleagues wrote that the USPSTF’s statements are unrealistic.

“Such intensive intervention is impractical for many families and is not included within many reimbursement frameworks. In addition, pediatric clinicians face the persistent challenges of treating obesity, including lack of time, lack of resources, and inadequate referral networks... By focusing on clinic-based interventions, the USPSTF recommendation reinforces a false dichotomy between individual-level, clinic-based obesity treatment interventions and population-level, policy-based prevention interventions,” they wrote. “At best, implementing the USPSTF recommendation will have modest effects on obesity prevalence in the United States. At worst, implementation could divert resources from population-health approaches to prevention and push practitioners to refer obese children and adolescents to intensive weight management programs that are ill-equipped to meet the demand and rarely exist within local communities.” – by Janel Miller

Disclosures : The researchers report no relevant financial disclosures.

References:

O’Connor EA, et al. JAMA. 2017:doi:10.1001/jama.2017.0332.

Thornton RL, et al. JAMA. 2017;doi:10.1001/jama.2017.3434. 

US Preventive Services Task Force. JAMA. 2017;doi:10.1001/jama.2017.6803.

The U.S. Preventive Services Task Force recommends that clinicians screen for obesity in children and adolescents aged at least 6 years and offer or refer them to comprehensive, intensive behavioral interventions to promote improvements in weight status, according to a report recently published in JAMA.

The task force gave such practices a B grade statement.

“Lifestyle-based weight-loss interventions with 26 or more hours of intervention contact are likely to help reduce excess weight in children and adolescents,” Elizabeth A. O’Connor, PhD, from Kaiser Permanente Research Center for Health Research, and colleagues wrote. “The clinical significance of the small benefit of medication use is unclear.”

The USPSTF cited data from the CDC that indicated about 17% of children and adolescents aged 2 to 19 years in the United States have obesity, and nearly 32% of children and adolescents have obesity or are overweight.

According to a press release, this recommendation is “largely consistent” with the 2016 draft recommendation USPSTF issued on this subject, but now contains the word adolescents to further clarify the population to which the recommendation applies.

In 2007, an AMA committee recommended that clinicians’ assessments include BMI calculation as behavioral and medical risk factors for obesity. The AAP agreed with those recommendations and recommended plotting BMI on a growth chart on a yearly basis for all patients aged at least 2 years, researchers stated.

In separate recommendations, the USPSTF also indicated it concluded separately that there is insufficient evidence to assess the balance of benefits and harms of screening for primary hypertension in asymptomatic children and adolescents to prevent subsequent CVD in childhood or adulthood, and insufficient evidence to assess the balance of benefits and harms of screening for lipid disorders in children and adolescents. Both of these recommendations received an I grade.

In an editorial related to the 26 hours of behavioral intervention the USPSTF recommended to treat childhood obesity, Rachel L.J. Thornton, MD, PhD, of the department of pediatrics at Johns Hopkins School of Medicine, and colleagues wrote that the USPSTF’s statements are unrealistic.

“Such intensive intervention is impractical for many families and is not included within many reimbursement frameworks. In addition, pediatric clinicians face the persistent challenges of treating obesity, including lack of time, lack of resources, and inadequate referral networks... By focusing on clinic-based interventions, the USPSTF recommendation reinforces a false dichotomy between individual-level, clinic-based obesity treatment interventions and population-level, policy-based prevention interventions,” they wrote. “At best, implementing the USPSTF recommendation will have modest effects on obesity prevalence in the United States. At worst, implementation could divert resources from population-health approaches to prevention and push practitioners to refer obese children and adolescents to intensive weight management programs that are ill-equipped to meet the demand and rarely exist within local communities.” – by Janel Miller

Disclosures : The researchers report no relevant financial disclosures.

References:

O’Connor EA, et al. JAMA. 2017:doi:10.1001/jama.2017.0332.

Thornton RL, et al. JAMA. 2017;doi:10.1001/jama.2017.3434. 

US Preventive Services Task Force. JAMA. 2017;doi:10.1001/jama.2017.6803.

    Perspective

    Caroline M. Apovian

    This systematic review investigates the role of the primary care provider in lifestyle interventions targeting children and adolescents with overweight and obesity. The review concludes that 26 hours of contact intervention or more would result in meaningful decreases in body weight in children and adolescents. Although the decrease in BMI z score of 0.2 is modest, the control groups in the studies reviewed gained weight throughout the time periods and the average increases were between 5 lb and 17 lb.

    The implications for this analysis is striking and can mean that altering the paradigm of how pediatricians approach patients with risk of future comorbidity can significantly reduce health care costs in the near future in the U.S. and elsewhere. The reduction in health care costs would be from prevention of hypertension, type 2 diabetes and, therefore, CVD.

    The goal would be assisting the primary care provider to offer intensive behavioral intervention in the office setting via a multidisciplinary team. This would mean a paradigm shift for the primary care provider office and team. Therefore, the recommendation statement published in JAMA suggests a plan that would take advantage of those offices that do indeed have the weight management team in place or if this is not the case — to refer to a program that does.

    Seventeen percent of children and adolescents are overweight or have obesity in the United States. These children have a higher prevalence of mental health and psychological issues as well as orthopedic and metabolic consequences that lead to CVD and type 2 diabetes at earlier ages. Although we have seen a stabilization of rapid increase in prevalence of overweight and obesity in the U.S., underserved populations such as African Americans and Hispanic children are still seeing an increase in rates. Causes continue to be targeted, such as sugar-sweetened beverage taxation and education for parents to help children increase physical activity and reduce television time.

    In addition to the public health initiatives that are being implemented, such as taxation of sugar-sweetened beverages, this recommendation from the USPSTF to offer or refer intensive weight management to children and adolescents with obesity should be foremost for pediatrician practices countrywide. Those practices that have the resources to implement intensive weight management counseling within the practice should do so as a priority for the coming year.

    • Caroline M. Apovian, MD, FACP, FACN
    • professor, medicine and pediatrics, Boston University School of Medicine and
      director, Nutrition and Weight Management Center at Boston Medical Center