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

Slide presentation from the AHRQ 2010 conference.

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).


Slide 1

Slide 1. Screening for Obesity in Pediatric Primary Care: Recommendations from the U.S. Preventive Services Task Force

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)

Slide 2

Slide  2. Disclosures

Disclosures

  • No financial disclosures.
  • Member of USPSTF.

Slide 3

Slide 3. Overweight trends among children and adolescents

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.

Slide 4

Slide 4. Background

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.

Slide 5

Slide 5. Definitions

Definitions

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

Slide 6

Slide 6. BMI-for-Age Percentiles for Boys Ages 2 to 20 Years

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.

Slide 7

Slide 7. Analytic Model: Child Obesity

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."

Slide 8

Slide 8. Key Question 1

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?

Slide 9

Slide 9. Key Question 2

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?

Slide 10

Slide 10. Key Question 3

Key Question 3

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

Slide 11

Slide 11. Methods

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.

Slide 12

Slide 12. Methods

Methods

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

Slide 13

Slide 13. Findings: Behavioral interventions

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.

Slide 14

Slide 14. Content of Behavioral Intervention

Content of Behavioral Intervention

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

Slide 15

Slide 15. Pooled analysis: short-term weight change effect size (ES) of behavioral interventions (KQ1)

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.

Slide 16

Slide 16. Other Outcomes

Other Outcomes

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

(n=7 trials)

Slide 17

Slide 17. Intensity

Level CareTime (hr)Prim
1. Very low<10Yes
2. Low10-25Yes
3. Medium26-75?
4. High>75No

Slide 18

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.

Slide 19

Slide 19. Plot of maintenance effect sizes (ES) of behavioral interventions (KQ2)

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.

Slide 20

Slide 20. Harms

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.

Slide 21

Slide 21. USPSTF Recommendation

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.

Slide 22

Slide 22. Harms

Harms

  • Adequate evidence that harms are no greater than small.

Slide 23

Slide 23. Net benefit

Net benefit

Moderate benefit 
very small harms
= moderate net benefit.

Level of Certainty: Moderate.

Slide 24

Slide 24. Recommendation Grade Formula

Recommendation Grade Formula

Certainty of Net BenefitMagnitude of Net Benefit
(Benefit Minus Harms)
SubstantialModerateSmallZero/Negative
HighABCD
ModerateBBCD
LowI Statement
Do: A & B: recommend routinely
Depends: C: recommend individual decision
Don't do D: recommend against
Don't know I statement: insufficient evidence

Slide 25

Slide 25. Clinical Considerations

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.

Slide 26

Slide 26. Clinical Considerations

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.

Slide 27

Slide 27. Clinical Considerations

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.

Slide 28

Slide 28. Dissemination

Dissemination

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

Slide 29

Slide 29. Questions?

Questions?

Email: grossman.d@ghc.org

Current as of December 2010
Internet Citation: Screening for Obesity in Pediatric Primary Care: Recommendations from the U.S. Preventive Service Task Force. December 2010. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/events/conference/2010/grossman/index.html