USPSTF recommends intensive behavioral interventions for children with high BMI

USPSTF recommends intensive behavioral interventions for children with high BMI | Image Credit: © udra11 - © udra11 - stock.adobe.com.

The US Preventive Services Task Force (USPSTF) has recommended that clinicians provide or refer children and adolescents aged 6 years and older with a high body mass index (BMI) (at or above the 95th percentile for age and sex) to comprehensive, intensive behavioral interventions. The task force assigned the recommendation with a "B" grade, indicating these interventions will, with "moderate certainty," provide a "moderate net benefit."^1,2

The recommendation statement published in JAMA noted that approximately 19.7% of children and adolescents aged 2 to 19 years in the United States from 2017 to 2020 have a BMI at or above the 95th percentile for age and sex. The rate of BMI increase almost doubled during the first 9 months of the COVID-19 pandemic, according to an editorial published in JAMA by Thomas N. Robinson, MD, MPH, and Sarah C. Armstrong, MD.²

The interventions the USPSTF refers to in its recommendation include at least 26 contact hours for up to 1 year and supervised physical activity sessions. Behavior change methods are also included, such as goal setting, self-monitoring, and problem-solving for healthy eating, screen time, and physical activity.²

The USPSTF reviewed pharmacotherapy to address high BMI in youth, as 4 medications (orlistat, liraglutide, phentermine/topiramate, and semaglutide) are currently FDA approved to treat long-term obesity in adolescents aged 12 years and older. The task force reviewed 8 trials that assessed pharmacotherapy interventions and noted that pharmacotherapy was associated with a larger mean reductions in BMI compared to placebo in most trials. All medications demonstrated increases in the likelihood of losing 5% and 10% of baseline weight or BMI.²

However, the USPSTF determined "the totality of the evidence was found to be inadequate," noting that only a single trial for each medication lasted longer than 2 months. The limited evidence for weight maintenance after pharmacotherapy discontinuation "suggests that weight rebound starts soon after discontinuation, implying that long-term use will be needed to maintain weight loss." The task force noted there is no evidence on the harms of long-term medication use, though it recognized pharmacotherapy is associated with moderate harms due to gastrointestinal symptoms. As a result, the USPSTF is encouraging providers to promote behavioral interventions as the primary effective intervention for weight loss in children and adolescents.¹

Fifty randomized clinical trials (n = 8798) examined behavioral interventions. Forty-one trials included individuals who had a BMI at or above the 85th percentile for their age or sex. Trials conducted in the United States (n = 28) featured the most diversity, mostly comprised of White (52.4%), Black (20.5%), and Hispanic/Latino (25%) study participants. Among trials that included patient participation, 31% to 39% of participants completed all sessions.¹

Though trials rarely reported health outcomes, pooled analyses demonstrated a statistically significant increase in global quality of life after 6 to 12 months (mean difference in change, 1.9 [95% CI, 0.2 to 3.5]; 11 RCTs; n = 1922). For studies with more contact hours (26 or more hours), the mean difference in change in quality of life measures was 3.8, as most scales ranged from 0 to 100 (95% CI, 3.6 to 4.1.)¹

After 6 to 12 months, behavioral interventions were associated with reductions in BMI and other weight-related outcomes, according to the USPSTF (mean difference in change between groups, −0.7 [95% CI, −1.0 to −0.3]; 28 RCTs [n=4494]; I² =86.8%).

Among 16 trials and 1700 participants, cardiometabolic risk factors were reported. Pooled analyses of trials provided 26 or more contact hours and physical activity that demonstrated improvements in blood pressure (mean difference in systolic blood pressure, −3.6 mm Hg [95% CI, −5.7 to −1.5 mm Hg]; 8 RCTs [n = 773];I² = 47.3%; mean difference in diastolic blood pressure, −3.0 mm Hg [95% CI, −5.7 to −1.5 mm Hg]; 8 RCTs [n = 774]; I² = 49.3%) and fasting plasma glucose level (mean difference, −1.9 mg/dL [95% CI, −2.7 to −1.2 mg/dL]; 4 RCTs [n = 367]; I² = 0%) after 6 to 12 months, according to the recommendation.¹

There were 18 trials that examined the harms of behavioral interventions with outcomes reported 6 to 12 months after baseline assessment. Overall, none of these trials revealed an increased risk of any adverse event or serious adverse events, including disordered eating, decreases in self-esteem or body satisfaction.¹

The task force identified gaps in evidence that require additional research, importantly, the need for longer-term outcomes (≥2 years and >5 years) of "benefits and harms; additional physiological, psychological, and behavioral outcomes in studies; more diverse and representative samples; studies of timing and combination of interventions; age group differences in outcomes; and best practices for non-stigmatizing, weight-related communication," wrote Robinson and Armstrong.²

Further, the task force is calling for evidence for strategies and policies that will help deliver broad adoption and installation of behavioral interventions to improve accessibility and health equity.²

In addition, the USPSTF is calling for broader social, political, and environmental changes, asking for public policies to make food, transportation, media, and health care more equitable, affordable, acceptable, and accessible.²

References:

1.) Interventions for High Body Mass Index in Children and Adolescents: US Preventive Services Task Force Recommendation Statement. US Preventive Services Task Force. JAMA. Published online June 18, 2024. doi:10.1001/jama.2024.11146

2.) Robinson TN, Armstrong SC. Treatment Interventions for Child and Adolescent Obesity: From Evidence to Recommendations to Action. JAMA. Published online June 18, 2024. doi:10.1001/jama.2024.11980