New recommendations from the U.S. Preventive Services Task Force advise that children aged 6 years and older should be screened for obesity using body mass index calculations, and should be offered or referred to services that provide intensive counseling and behavioral interventions to promote improvements in their weight status.
The task force found enough evidence to rule that the net benefit is moderate for screening children in that age range and for offering or referring children to moderate- to high-intensity intervention programs.
Dr. Ned Calonge, chair of the USPSTF, said in an interview that many pediatric care providers have been reluctant to perform screening for overweight and obesity and to refer patients for treatment because of “a real sense that it doesn't work.”
But “the good news is that we actually have evidence that this [recommendation]—if there is a referral center available—actually works.”
Dr. Calonge said it should be easy to screen for overweight and obesity with BMI calculations because clinicians routinely measure height and weight at office visits, but he recognized that it will be difficult for some clinicians to offer counseling and behavioral services and that some patients will not be able to afford the interventions without adequate insurance coverage.
The evidence in support of the efficacy of moderate- to high-intensity interventions should help to change insurance coverage for them, said Dr. Calonge, chief medical officer of the Colorado Department of Public Health and Environment.
To fit screening and counseling referrals into an already busy office visit, Dr. Calonge said he tells clinicians that they “should focus on the anticipatory guidance for which we have good evidence of efficacy [for interventions], and it could take the place of guidance that we don't have evidence for.”
When the USPSTF last conducted a review of the available evidence in 2005, the group found adequate evidence to recommend BMI as an acceptable measure for identifying children and adolescents with excess weight but did not make screening or treatment recommendations.
Since then, nine additional interventional trials in children aged 4-18 years have been reported. These new studies have shown that treatment for obesity, especially comprehensive treatment, can be effective and has effects that extend beyond the immediate intervention time period.
The USPSTF did not find sufficient evidence for screening children younger than age 6 years. This is “surprising” according to Dr. Sandra G. Hassink, a member of the American Academy of Pediatrics board of directors, because “in recent years, universal screening for overweight and obesity has become standard of care in pediatrics and has been recommended by the American Academy of Pediatrics and the [American Medical Association] Expert Committee.”
In 2007, an expert committee organized by the AMA made recommendations similar to those from the USPSTF. The association advised calculating BMI, assessing patients for medical and behavioral risks for obesity, and using a stepwise approach to treatment that includes counseling, a structured weight management plan, and a comprehensive intervention delivered by multidisciplinary teams with expertise in childhood obesity. The AAP later endorsed the AMA's recommendations, adding that BMI should be plotted annually for all patients aged 2 years and older.
By limiting their recommendations to children aged 6 years and older, the task force “falls short of the mark in not recognizing the developmental trajectory of obesity in childhood,” Dr. Hassink of A.I. DuPont Hospital for Children, Wilmington, Del., wrote in an editorial (Pediatrics 2010;125:387-8).
The task force also found no evidence on appropriate screening intervals.
In the studies that the task force examined, the outcomes of interventions appeared to be related to the level of intensity of the intervention.
In comprehensive, moderate- to high-intensity behavioral interventions, investigators reported modest improvements in weight status. These trials found 1.9-3.3 kg/m2 declines in mean BMI 6-12 months after starting treatment.
Based on the 50th percentile for height, a decline in BMI of 3.3 kg/m2 is equivalent to an 8-year-old boy losing 13 pounds, a 16-year-old girl losing about 19 pounds, and a 16-year-old boy losing 22-23 pounds (Pediatrics 2010;125:361-7).
Comprehensive interventions were defined as those that included counseling for weight loss or healthy diet; counseling for physical activity or a physical activity program; and instruction in and support for the use of behavioral management techniques. The intensity of an intervention was considered to be very low with less than 10 hours of contact, low with 10-25 hours, moderate with 26-75 hours, and high with greater than 75 hours.
In trials that combined drug treatments with behavioral interventions in obese adolescents, participants aged 12-18 years had 1.6-2.7 kg/m2 greater declines in BMI when sibutramine (Meridia) was combined with a behavioral intervention than when placebo was added to the behavioral intervention.
Combined treatment with orlistat (marketed as Xenical by prescription and Alli over the counter) and a behavioral intervention for 12 months resulted in a small, but statistically significant 0.85 kg/m2 reduction in BMI.
Sibutramine has not been approved by the Food and Drug Administration for use in pediatric populations, whereas orlistat has been approved for use in children aged 12 years and older.
Weight management programs have not been reported to have adverse effects on growth, eating disorder pathology, or mental health.
Few serious adverse events have been reported in pediatric patients taking sibutramine or orlistat, although sibutramine users were more likely than were placebo users to have small increases in heart rate or blood pressure.
Some users of sibutramine also have reported mild to moderate adverse gastrointestinal side effects.
Disclosures: None was reported.
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