About one in three children and adolescents are currently overweight or obese. Research shows that childhood and adolescent obesity can cause health problems such as asthma, hypertension and sleep apnea. And if steps aren't taken to improve these young patients' health, greater health problems -- such as diabetes and cardiovascular disease -- can develop in adulthood.
The U.S. Preventive Services Task Force (USPSTF) recently re-examined this issue and on Nov. 1, posted a draft recommendation statement(www.uspreventiveservicestaskforce.org) and draft evidence review(www.uspreventiveservicestaskforce.org) on screening for obesity in children and adolescents.
Based on its evidence review, the USPSTF recommends screening for obesity in children and adolescents ages 6-18 and offering or referring patients who are diagnosed with obesity to comprehensive, intensive behavioral interventions to promote improvements in weight status. This is a "B" recommendation.(www.uspreventiveservicestaskforce.org)
According to the task force, such comprehensive, intensive interventions
- The U.S. Preventive Services Task Force recommends screening children and adolescents ages 6-18 for obesity and offering or referring patients with a positive result to comprehensive, intensive behavioral interventions.
- This draft recommendation is largely consistent with the USPSTF's 2010 final recommendation but adds "adolescents" to further clarify the population to which the recommendation applies.
- The task force previously found evidence that body mass index (BMI) is an adequate screening measure to identify children and teens with obesity; children are considered obese if they have a BMI at or above the 95th percentile for their age and sex.
- involve at least 26 contact hours;
- may include sessions that target both the child and parent;
- offer information on healthy eating and safe exercise;
- discuss the use of stimulus control, such as limiting access to tempting foods and screen time; and
- include supervised physical activity.
"Parents do not always recognize when their children are overweight," said USPSTF member Alex Kemper, M.D., M.P.H., M.S., in a news release.(www.uspreventiveservicestaskforce.org) "Looking at BMI, or body mass index, as part of usual health care provides an opportunity to identify children who have obesity and refer them to a comprehensive program, leading to improved health outcomes."
This draft recommendation is largely consistent with the USPSTF's 2010 final recommendation but adds the term "adolescents" to further clarify the population to which the recommendation applies.
In 2010, the AAFP also recommended that family physicians screen children ages 6 and older for obesity and offer them or refer them to comprehensive, intensive behavioral interventions to promote improvement in weight status.
The USPSTF examined the evidence on screening for obesity in children and adolescents and the benefits and harms of weight management interventions. Bariatric surgery, reserved for patients with morbid obesity that is easily identified without screening, and obesity prevention interventions for children whose weight is within normal parameters were considered to be outside the scope of this review.
The task force previously found evidence that BMI is an adequate screening measure to identify children and adolescents with obesity; children are considered obese if they have a BMI at or above the 95th percentile for their age and sex.
The USPSTF reviewed 45 trials of behavioral interventions for obesity, with 42 trials using multicomponent interventions that targeted lifestyle change (e.g., counseling on diet, increasing physical activity/decreasing sedentary behavior and addressing behavior change) to limit weight gain or decrease weight. Three smaller trials assessed different behavioral approaches (weight loss maintenance, regulation of cues for overeating and interpersonal therapy).
Of the 42 behavioral intervention trials, eight were of good quality and 34 were of fair quality. Average baseline BMI was 18.7 kg/m2 in trials involving preschool-age children, 23.5 kg/m2 in trials involving elementary school-age children and 32.2 kg/m2 in trials involving adolescents.
Total time of intervention contact ranged from one to 122 hours across multiple sessions. Seven studies had 52 contact hours or more, nine studies had 26 to 51 contact hours, 11 studies had six to 25 contact hours and 15 studies had 15 contact hours or less. These sessions took place during a period that ranged from 2.25 to 24 months.
The trials with five or fewer hours of contact time were often conducted in primary care settings and involved individual sessions.
Interventions with more contact time
- included group sessions, with or without individual sessions;
- targeted the child, parents or both; and
- usually took place in specialty settings.
In addition, trials with 52 or more contact hours often included supervised physical activity sessions, as did about half of the trials with 26 to 51 contact hours.
Most participants maintained their baseline weight within five pounds while growing in height. And interventions were effective in reducing excess weight in children and adolescents after six to 12 months.
As for pharmacotherapeutic interventions, metformin and orlistat (Xenical, Alli) were associated with small reductions in excess weight (BMI reduction of less than 1 kg/m2, or about 5 to 7 pounds) compared with placebo. However, these drugs also produced mild to moderate gastrointestinal side effects, which led the USPSTF to conclude these drugs provide small to no benefit on health outcomes.
Family Physician's Take
Jennifer Frost, M.D., medical director for the AAFP Health of the Public and Science Division, told AAFP News that unfortunately, simply telling children and their parents to eat a healthy diet and be more physically active doesn't generally result in sustainable behavior change.
To make a significant change in weight, Frost agrees with the USPSTF that intensive behavioral intervention is needed -- that is, intervention involving at least 26 contact hours.
Furthermore, she said, "In order to make a difference for a child, the whole family needs to be involved, all of them participating in a healthier diet and physical activity."
As for catching obesity issues as early as possible, Frost said this is especially important as rates of type 2 diabetes and hypertension in children continue to increase. "However, there isn't any evidence that intervening earlier results in better outcomes later," she acknowledged.
The USPSTF is accepting public comments on this draft recommendation statement(www.uspreventiveservicestaskforce.org) and draft evidence review(www.uspreventiveservicestaskforce.org) until Nov. 28.
The AAFP will review the task force's draft materials and release its own final recommendation after the USPSTF finalizes its recommendation statement.
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