On June 20, the U.S. Preventive Services Task Force (USPSTF) published a final recommendation statement(www.uspreventiveservicestaskforce.org) and evidence summary(www.uspreventiveservicestaskforce.org) on screening children and teens for obesity. Based on its evidence review, the USPSTF recommended obesity screening for children and adolescents ages 6-18 and also recommended offering or referring patients who are diagnosed with obesity to comprehensive, intensive behavioral interventions to promote improved weight status. This is a "B" recommendation.(www.uspreventiveservicestaskforce.org)
According to the task force, such comprehensive, intensive interventions
- involve at least 26 patient contact hours;
- may include sessions that target both the child and his or her parents;
- provide information on healthy eating and safe exercise;
- may entail discussions about using stimulus control, such as limiting access to tempting foods and screen time; and
- incorporate supervised physical activity.
"Parents don't always recognize when their children are overweight, so it is important for clinicians to measure BMI, or body mass index, as part of regular health care," said USPSTF Chair David Grossman, M.D., M.P.H., in a news release.(www.uspreventiveservicestaskforce.org) "Children with obesity should be referred to programs that help them manage weight and improve their overall health."
- 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 final recommendation is largely consistent with the USPSTF's 2016 draft recommendation and its 2010 final recommendation but adds the term "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 gender.
This final recommendation is largely consistent with the USPSTF's 2016 draft recommendation and its 2010 final recommendation but adds the term "adolescents" to further clarify the population to which this recommendation applies.
In 2010, the AAFP also recommended that family physicians screen children ages 6 and older for obesity and offer or refer them to comprehensive, intensive behavioral interventions "to promote improvement in weight status."
Response to Public Comment
A draft version of the final recommendation statement was posted for public comment on the USPSTF website from Nov. 1-28, 2016.
Many commenters asked for further explanation of the components of effective interventions. In response, the task force added language under the "Effectiveness of Early Detection and Interventions" subheading of the "Discussion"(www.uspreventiveservicestaskforce.org) section of the final recommendation statement that describes these components and identifies the various health professionals who would deliver these types of care.
Another frequent concern from commenters was the absence of a recommendation for children younger than 6. To answer this concern, the USPSTF added language in the final recommendation statement that cited a lack of evidence to support obesity screening in young children.
Finally, the task force responded to additional comments by adding language about the frequent lack of subgroup analyses of prespecified populations in the trials examined, as well as about access and research gaps.
The USPSTF examined the evidence on screening for obesity in children and adolescents and the benefits and harms of various 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 teens with obesity; individuals are considered obese if they have a BMI at or above the 95th percentile for their age and gender.
The USPSTF reviewed 45 trials involving behavioral interventions for obesity, of which 42 used multicomponent interventions that targeted lifestyle changes (e.g., counseling on diet, increasing physical activity/decreasing sedentary behavior and addressing behavior change) to limit weight gain or to reduce weight. Three smaller trials assessed different behavioral approaches (weight loss maintenance, regulation of overeating cues and interpersonal therapy).
Of the 42 behavioral intervention trials, eight were of good quality and 34 were of fair quality. Forty-three percent of the trials evaluated were conducted in primary care settings, and 43 percent took place in another health care setting. The remaining trials were conducted outside of a health care setting. Average baseline BMI was 18.7 kg/m2 in trials that involved preschoolers, 23.5 kg/m2 in trials that involved elementary school-age children and 32.2 kg/m2 in trials that involved adolescents.
Time of contact for the various interventions ranged from 15 minutes to 122 hours (across one to 122 sessions). Seven studies involved 52 contact hours or more, nine involved 26 to 51 contact hours, 11 involved six to 25 hours and 15 studies involved 15 hours or fewer. These sessions took place during a period that ranged from 2.25 to 24 months.
Whereas trials involving five or fewer hours of contact time were often conducted in primary care settings and involved individual sessions, those involving 52 or more contact hours
- included group sessions, with or without individual sessions;
- targeted the child, parents or both; and
- often took place in specialty settings.
In addition, trials that involved 52 or more contact hours often included supervised physical activity sessions, as did about half of the trials that involved 26 to 51 contact hours.
Most participants in the intervention groups maintained their baseline weight within five pounds while growing in height. Interventions were effective in reducing excess weight in children and teens after six to 12 months.
As for pharmacotherapeutic interventions, although a number of studies found that metformin and orlistat (Xenical, Alli) were associated with small reductions in excess weight compared with placebo, the clinical significance of this benefit could not be determined because evidence regarding the drugs' effectiveness was inadequate. The drugs did, however, produce mild to moderate gastrointestinal side effects, which led the USPSTF to conclude that overall, these drugs provide little to no benefit on health outcomes.
Jennifer Frost, M.D., medical director for the AAFP Health of the Public and Science Division, told AAFP News that the Academy sent comments to the USPSTF during last year's comment period.
The AAFP will now review the task force's final recommendation and evidence review and release its own final recommendation.
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