USPSTF Recommends Interventions for Youth With High BMI
Task Force Calls for Behavioral Weight Management Strategies
Aug. 9, 2024, Cindy Borgmeyer — According to recent CDC figures, nearly one in five U.S. children and teens ages 2−19 years has obesity, defined as a body mass index at or above the 95th percentile for their age and sex. The prevalence of high BMI increases with age and is higher among Hispanic/Latino, Native American/Alaska Native, and non-Hispanic Black children and adolescents. Children from lower-income families also are at increased risk.
It is against this backdrop that the U.S. Preventive Services Task Force has finalized a recommendation calling for physicians to “provide or refer children and adolescents 6 years or older with a high body mass index (≥95th percentile for age and sex) to comprehensive, intensive behavioral interventions.” This replaces the task force’s 2017 recommendation on screening for obesity in children and adolescents and is a grade “B” recommendation.
Review of Evidence
As AAFP News reported in January, to update its previous recommendation, the USPSTF commissioned a systematic evidence review on interventions (behavioral counseling and pharmacotherapy) for weight loss or weight management that can be provided in or referred from a primary care setting. Fifty-eight randomized clinical trials were included in the review.
Of the 50 RCTs that examined solely behavioral interventions, most did not report on race or ethnicity or included predominantly white study participants. RCTs conducted in the United States (n=28) demonstrated comparatively greater study population diversity, but even those trials still mostly involved only white (52.4%), Black (20.5%), and Hispanic/Latino (25%) study participants, with few Asian American or Native American/Alaska Native participants. In total, the RCTs included nearly 8,800 children and adolescents ages 2−19 years, with a mean BMI percentile of 93.
Eight RCTs involving 1,345 participants assessed pharmacotherapy interventions (i.e., liraglutide, semaglutide, orlistat, and phentermine/topiramate). Five of them also included behavioral counseling components. Most study participants were age 12 or older or 14 or older; one study included children ages 7−11 years. Only a single trial per medication had a treatment duration of 12 months or longer.
Story Highlights
Findings and Research Gaps
Overall, structured behavioral weight management interventions were associated with small reductions in BMI and modest reductions in weight after six to 12 months, with interventions that included ≥26 contact hours and offered physical activity sessions showing the greatest effects. Although few studies found significant improvements in quality of life, pooled analyses found small increases in total and physical quality of life after six to 12 months. No effect on other psychosocial outcomes was seen. Pooled effects of behavioral weight management interventions showed no impact on measures of cholesterol, but slight improvements in blood pressure and fasting plasma glucose were seen in trials offering ≥26 hours of contact, most of which also offered physical activity sessions. Trials that assessed potential harms of behavioral interventions found no increased risk of any adverse event or serious adverse events, including disordered eating, or decreases in self-esteem or body satisfaction.
“We know that there are proven strategies to help kids who have a high BMI achieve a healthy weight,” said USPSTF Chair Wanda Nicholson, M.D., M.P.H., M.B.A., in an ACIP news bulletin. “These interventions work best when both kids and parents are engaged, so it is important that health care professionals provide support in identifying which counseling interventions are available, accessible and a good fit for the family.”
Of medications evaluated, only semaglutide showed improvement in weight-related quality of life. Pharmacotherapy overall was associated with larger mean BMI reductions compared to placebo in most trials, with semaglutide and phentermine/topiramate demonstrating the largest effects. Still, the task force found the totality of the evidence to be inadequate. Furthermore, the limited evidence on weight maintenance after stopping pharmacotherapy suggests that weight rebound starts soon after discontinuation, implying that weight loss can only be maintained with long-term use. However, evidence regarding the harms of long-term medication use is absent. Finally, pharmacotherapy was associated with moderate gastrointestinal harms. Based on these factors, the USPSTF encourages clinicians to promote behavioral interventions as the primary effective intervention for weight loss in children and adolescents.
Further research is needed in several areas, said the task force, including long-term (≥two years) health outcomes and benefits of behavioral and pharmacotherapy interventions, long-term psychosocial harms of pharmacotherapy, weight loss maintenance after behavioral interventions and assessment of long-term (>five years) benefits and harms, and best practices for discussing weight with children and families.
Family Physician Perspective
AAFP News asked obesity medicine expert Catherine Varney, D.O., FAAFP, FOMA, DABOM, for her thoughts on the USPSTF recommendation and its implementation. Varney is an assistant professor in the Department of Family Medicine at the University of Virginia School of Medicine and obesity medicine director at UVA Health. She serves as the AAFP liaison to the STOP (Strategies to Overcome and Prevent) Obesity Alliance and is a co-author of the Academy’s recently released practice manual, Addressing Health Disparities for Patients With Obesity.
Varney largely agreed with the task force’s recommended behavioral approach to caring for these patients, but she cautioned against dismissing pharmacotherapy out of hand.
“Behavioral therapies, such as cognitive behavioral therapy and structured lifestyle interventions, have demonstrated substantial benefits in promoting sustained weight loss and improving overall health outcomes,” she said. “However, it is important to recognize that implementing behavioral therapy can be labor- and resource-intensive. These programs often require trained professionals, time-intensive sessions, and continuous follow-up, which can pose logistical and financial challenges.”
Many physicians who care for pediatric patients are ill prepared to provide this counseling because they lack the education and training to do so, Varney explained, adding that a majority of physicians receive 10 hours or less of training on this topic during medical school and residency.
It’s also important not to minimize what evidence exists for this population showing that weight regain is common after weight loss with behavioral interventions, she added. That, combined with clear evidence of the negative impact of untreated obesity, with its attendant increased risks for diabetes, heart disease and certain cancers, should drive home the need for long-term studies to evaluate these issues.
Recommendations for Practice
According to the USPSTF, no evidence demonstrated the relative benefits of specific intervention components. Rather, the task force noted that “effective interventions commonly included supervised physical activity sessions; provided information about healthy eating, safe exercising, and reading food labels; and incorporated behavior change techniques such as problem solving, monitoring diet and physical activity behaviors, and goal setting.” Interventions may include activities targeting both the parent and child (separately, together or both) and can be offered in group settings as well as in individual or single-family sessions. To be effective, they must involve at least 26 contact hours with a health care professional — or team of professionals — over the course of up to one year. In addition to physicians, disciplines involved may include exercise physiologists or physical therapists, dietitians or diet assistants, psychologists or social workers, or other behavioral specialists.
The Community Preventive Services Task Force has evaluated multiple evidence-based interventions aimed at curbing obesity in both youth and adults in community, school and other settings and recommends a range of options. Examples include behavioral interventions aimed at cutting recreational screen time, digital health interventions for teens and multicomponent interventions to increase availability of healthier foods and beverages in schools.
Other helpful resources include HHS’ Physical Activity Guidelines for Americans, which provides recommendations for physical activities to help promote health and reduce chronic disease risk for Americans ages 3 years and older, and obesity-related guidance and tools from the CDC.
The AAFP offers extensive clinical guidance and practice resources on obesity and healthy lifestyle, as well as CME activities such as Obesity CME for the Family Physician and Practical Approaches to Improving Obesity Care. American Family Physician also has compiled a collection of its best content on the topic. Finally, familydoctor.org offers information on topics such as dealing with weight issues in children, developing healthy eating habits, how to avoid overeating in children and teens, and helping children achieve a healthy weight.
Final Thoughts
Another problematic issue with this recommendation, according to Varney: There simply are not enough physicians and other health care professionals to refer to.
“As of April 2024,” she explained, “the Bureau of Labor Statistics estimated that there were 73,860 dietitians and nutritionists in the United States. That means that there is one registered dietitian for every 200 children with elevated BMI. This doesn’t factor in a couple of things; it doesn’t account for the nearly 100 million adults with obesity in the U.S. who may need these services as well — that would change the ratio to one RD for every 1,553 adults and children.” It also doesn’t address the challenges of providing access to vulnerable populations, such as rural patients, Varney added.
Still, some options to tackle these shortfalls do exist, she contended. “Family medicine physicians can get more training and education on this topic through the AAFP, the Obesity Medicine Association and the American Academy of Pediatrics. They can advocate for their clinic or health system to add this service for their patients.”
If funding is lacking, Varney suggested applying for grants or starting slow by bringing in nutritional education one time per week or month. Even gathering and distributing evidence-based handouts in the office can help provide brief interventions.