Screening for Obesity in Pediatric Primary Care: Recommendations from the U.S. Preventive Service Task Force

On September 28, 2010, David Grossman made this presentation at the 2010 Annual Conference. Select to access the PowerPoint® presentation (1 MB). (Plugin Software Help).

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Screening for Obesity in Pediatric Primary Care: Recommendations from the U.S. Preventive Service Task Force

David Grossman, MD, MPH
Group Health Research Institute
Member, U.S. Preventive Services Task Force (USPSTF)

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Disclosures

• No financial disclosures.
• Member of USPSTF.

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Figure 1. Overweight trends among children and adolescents

Image: Line graph shows percent of overweight children and adolescents rising from around 5 percent in 1963-1965 up to 15 percent by 1999-2002 for ages 6 to 11, 12 to 19 years, and up to 10 percent for ages 2-5 years.

Source: Whitlock EP, et al. Pediatrics 2005;116:e125-e144.

Copyright ©2005 American Academy of Pediatrics.

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Background

• 2005: USPSTF stated that there was 'insufficient evidence' to recommend screening.
• Rationale:
  • Body Mass Index (BMI) effective screening tool.
  • Evidence for effective interventions inadequate.

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Definitions

• Obese: age/gender specific BMI >95th percentile.
• Overweight: age/gender specific BMI between 85th-95th percentile.

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BMI-for-Age Percentiles for Boys Ages 2 to 20 Years

Image: Line graph shows BMI-for-age percentiles for boys ages 2 to 20 years rising with age.

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Analytic Model: Child Obesity

Image: The analytic model depicts the framework for screening for obesity in children and adolescents. The diagram starts on the left with "Children or adolescents ages 2 to 18 years old identified as obese or overweight according to age-and sex-specific criteria." An arrow numbered 1 leads to the right and is captioned "Intervention." This arrow forks in three directions. The first part, numbered 2 proceeds up and to the right to a box labeled "BMI maintenance." The second part, numbered 3 curves down and points to an oval labeled "Adverse effects." The third fork proceeds to the right, to a box labeled "BMI reduction or stabilization." From there, another arrow numbered 2 proceeds to the right to the box labeled "BMI maintenance." Another arrow numbered 3 points down at the oval reading "Adverse effects." On the other side of "BMI maintenance," arrow 2 becomes a dashed line and proceeds to the final box of the diagram. The box contains three outcomes: "Decreased childhood morbidity," "Improved childhood functioning," and "Reduced adult morbidity and mortality."

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Key Question 1

• Do weight-management programs (behavioral, pharmacologic) lead to BMI, weight, or adiposity stabilization or reduction in children and adolescents who are obese (≥95th BMI percentile) or overweight (85�94th percentile)?
  • KQ1a. Do these programs lead to other positive outcomes (e.g., improved behavioral or physiologic measures, decreased childhood morbidity,improved childhood functioning, or reduced adult morbidity and mortality)?
  • KQ1b. Do specific components of the programs influence the effectiveness of the programs?
  • KQ1c. Are there population or environmental factors that influence the effectiveness of the programs?

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Key Question 2

• Do weight-management programs (behavioral, pharmacologic) help children and adolescents who were initially obese or overweight maintain BMI, weight, or adiposity improvements after the completion of an active intervention?
  • KQ2a. Do these programs lead to other positive outcomes (e.g., improved behavioral or physiologic measures, decreased childhood morbidity, improved childhood functioning, or reduced adult morbidity and mortality)?
  • KQ2b. Do specific components of the programs influence the effectiveness of the programs?
  • KQ2c. Are there population or environmental factors that influence the effectiveness of the programs?

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Key Question 3

• What are the adverse effects of weight-management programs (behavioral, pharmacologic) attempting to stabilize, reduce, or maintain BMI?

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Methods

• Systematic literature review conducted by Oregon Evidence-based Practice Center.
• 2786 abstracts and 369 articles reviewed.
• Behavioral interventions classified by 'intensity'.
• Meta-analyses conducted for short-term and maintenance outcomes.
• Primary outcome was BMI change.

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Methods

• USPSTF team assisted with development of analytic model, review scope and resolution of methodologic issues.
• Evidence synthesis reviewed by 8 external peer-reviewers.

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Findings: Behavioral interventions

• New information available.
• 11 fair/good quality trials:
  • Only 2 were available during last review.
• Study participants: BMI >95th percentile.
• High degree of consistency of direction of benefit in behavioral trials.
• Magnitude of effect varied by intensity.

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Content of Behavioral Intervention

• All but 3 were comprehensive.
• Dietary weight loss counseling.
• Physical activity counseling.
• Behavioral modification techniques.
• Many involved families.

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Figure 3. Pooled analysis: short-term weight change effect size (ES) of behavioral interventions (KQ1)

Image: A table compares studies analyzing short-term changes in weight in children after behavioral interventions.

Source: Whitlock EP, et al. Pediatrics 2010;125:e396-e418.

Copyright ©2010 American Academy of Pediatrics.

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Other Outcomes

• Lipids decreased.
• Blood pressure decreased.
• Glucose/insulin decreased.
• Psychosocial measures were insufficient
• Clinical significance unknown

(n=7 trials)

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Combined Behavioral and Pharmacologic Studies

• 7 trials fair/good quality (total N=1294):
  • (Sibutramine or orlistat) + counseling.
  • Age 12-19 years.
  • >95th percentile BMI.
  • 6/7 funded by industry.
• Variable trial sizes; all showed BMI reductions.
• Two largest trials showed significant reductions (Δ BMI 0.85-2.6).
• Poor evidence that weight loss maintained after stopping medication.

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Plot of maintenance effect sizes (ES) of behavioral interventions (KQ2)

Image: A table compares studies analyzing maintenance of weight change in children after behavioral interventions.

Source: Whitlock EP, et al. Pediatrics 2010;125:e396-e418.

Copyright ©2010 American Academy of Pediatrics.

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Harms

• Few serious adverse effects.
• Exercise injury (small).
• Sibutramine (small):
  • Increased heart rate.
  • Blood pressure rise.
• Orlistat (small):
  • Gastrointestinal side effects common:
    • 20%-30% spotting, abdominal pain, urgency.

• 6/13 behavioral trials reporting.
• 5/7 combined trials reporting.

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USPSTF Recommendation

• Adequate evidence:
  • Multi-component, moderate-to-high-intensity behavioral interventions yield short term improvements in weight status.
• Inadequate evidence:
  • Effectiveness for low-intensity interventions.

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Harms

• Adequate evidence that harms are no greater than small.

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Net benefit

Moderate benefit 
very small harms
= moderate net benefit.

Level of Certainty: Moderate.

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Recommendation Grade Formula

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Clinical Considerations

• BMI chart acceptable measure for screening.
• Applies to:
  • Children and teens ages 6-18 years.
  • Obese children but not overweight.
• Long-term outcomes unknown.
• Most interventions in referral settings.

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Clinical Considerations

• Medications:
  • Harms data based on small numbers.
  • Effects may be limited to duration of use.
  • Approved for ages:
    • Orlistat: ≥12 years.
    • Sibutramine: ≥16 years.

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Clinical Considerations

• Screening intervals.
• Research needs and gaps:
  • Which components of multi-component interventions work?
  • Long-term follow-up needed for benefits and harms.
  • Primary care based interventions.
  • Interventions for young children.

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Dissemination

• From recommendations to practice.
• HEDIS measure:
  • BMI screening.
• Use of electronic medical record tools to promote screening.
• Need for behavioral intervention programs.

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Questions?

Email: grossman.d@ghc.org