The U.S. Preventive Services Task Force, or USPSTF, has updated its screening recommendations(www.ahrq.gov) for obesity in children and adolescents. The task force now recommends that clinicians screen children ages 6 years and older for obesity and offer them -- or refer them to -- comprehensive, intensive behavioral interventions to improve their weight status.
After a review by the AAFP Commission on Health of the Public and Science, the Academy has adopted the USPSTF recommendations.
According to the USPSTF, childhood and adolescent obesity has increased three- to sixfold in the past three decades. The task force now estimates that 12 percent to 18 percent of American children and adolescents ages 2-19 years are obese. The task force defines overweight as an age- and gender-specific body mass index, or BMI, between the 85th and 94th percentiles, and obesity is defined as a BMI at or above the 95th percentile.
In recommendations issued in 2005, USPSTF members concluded that the evidence was insufficient to recommend for or against routine screening for overweight in children and adolescents. At that time, the task force said that although roughly 15 percent of U.S. children and adolescents ages 6-19 years were overweight and at risk for developing chronic conditions -- including diabetes and high blood pressure -- it found insufficient evidence to support the effectiveness of behavioral counseling or other preventive interventions that could be conducted in primary care settings or to which primary care physicians could make referrals. The USPSTF also said at that time that it found insufficient evidence to assess the magnitude of the potential harms of screening, prevention or treatment.
New recommendations from the U.S. Preventive Services Task Force, or USPSTF, regarding screening for childhood and adolescent obesity call for moderate- to high-intensity interventions for obese patients.
In its recommendations, the task force acknowledged that such interventions, which require more than 25 hours of physician contact during a six-month period, likely will not take place in the primary care setting but, rather, will require a referral to specialty care.
However, receiving such care could pose significant challenges for many American children and their families. According to data from the Child and Adolescent Health Measurement Initiative's 2007 National Survey of Children's Health(mchb.hrsa.gov), 9.2 percent of children had no insurance, and 23.5 percent had inadequate insurance.
Furthermore, 11.5 percent of children had not had a single visit for preventive care in the previous 12 months, and 42.5 percent did not have a medical home.
However, in its new recommendations, the task force said there now is adequate evidence to show that the harms of behavioral interventions are "no greater than small," and there is moderate certainty that the net benefit is moderate for screening for obesity in children ages 6 years and older and for offering or referring children for moderate- to high-intensity interventions.
USPSTF members defined moderate- to high-intensity programs as those that involved more than 25 hours of physician contact with a child and/or the child's family during a six-month period; the results of such programs, they said, included improved weight status, defined as an absolute and/or relative decrease in BMI 12 months after beginning the intervention.
The task force said it was unknown whether these results can be applied to children who are overweight but not obese.
The task force said low-intensity interventions, defined as those that involved 25 or fewer hours of physician contact during a six-month period, did not result in significant improvement.
According to the USPSTF, moderate- to high-intensity interventions would not be feasible in the primary care setting, and primary care clinicians should refer patients for these interventions. Moderate- to high-intensity interventions conducted in trials took place in specialty health care facilities.
The task force said effective, comprehensive weight-management programs incorporated counseling and other interventions that targeted diet and physical activity. Additional interventions included behavioral management techniques. Interventions that focused on younger children integrated parental involvement.
The USPSTF said interventions that combined pharmacologic agents -- the prescription appetite suppressant sibutramine, which is marketed as Meridia, or the lipase inhibitor orlistat, which is marketed in a prescription formulation as Xenical and in an OTC formulation as Alli -- with behavioral interventions resulted in modest short-term improvement in weight status among children ages 12 and older.
However, the task force cautioned that no long-term data exist on the maintenance of improvement after discontinuation of such medications, and the magnitude of the harms of these drugs in children was uncertain. Adverse effects associated with their use included elevated heart rate, elevated blood pressure and gastrointestinal effects.
Meanwhile, a study(jama.ama-assn.org) published in the Jan. 20 issue of the Journal of the American Medical Association, or JAMA, found that the prevalence of high BMI among children and teens leveled off between 1999 and 2006.
The JAMA researchers differed from the USPSTF in that they used three cut points to measure high BMI. The article estimates that in 2007-08, 16.9 percent of children and adolescents ages 2-19 years were at or above the 95th percentile, including 11.9 percent that were at or above the 97th percentile. Nearly one-third were at or above the 85th percentile.
Children and adolescents who are obese have increased risks of developing type 2 diabetes mellitus, asthma and nonalcoholic fatty liver disease; are more likely to have cardiovascular risk factors; and have a greater anesthesia risk. They also may experience more mental health issues, including depression, the USPSTF said.
Moreover, according to the JAMA article, 9.5 percent of infants and toddlers were at or above the 95th percentile in 2007-08. The task force, however, said it did not find sufficient evidence to recommend screening children younger than age 6 years.