Evidence for Effective Obesity Treatment: Pediatricians on the Right Track!

The obesity epidemic has been part of the pediatric landscape since the 1980s and is now one of the most common issues that pediatricians confront in their day-to-day practice. From the first National Health and Nutrition Examination Survey (NHANES) (1971–1974) to NHANES 2003–2006, obesity (BMI > 95th percentile for age and gender) increased from 5.0% to 12.4% in children aged 2 to 5 years, from 4.0% to 17.0% in children aged 6 to 11 years, and from 6.1% to 17.6% in adolescents (aged 12–19 years).1–4 Although there is evidence that these rates have begun to stabilize,4 this leaves us with 16.3% of 2- to 19-year-olds with BMI values above the 95th percentile and 31.9% above the 85th percentile.5To update their recommendations, the US Preventive Services Task Force (USPSTF) was asked to “examine benefits and harms of behavioral and pharmacological weight management interventions for overweight and obese children and adolescents.”6 The evidence review included the intensity and comprehensiveness of interventions as well as initial outcomes and maintenance of outcomes over 12 months.The proliferation of evidence is reflected in 9 later studies that were not available for the 2005 USPSTF report.7 These studies included children aged 4 to 18 years; successful outcomes were considered to be reduction of BMI, BMI SD score, or percentage overweight that resulted from either weight loss or weight-gain prevention. There was a positive association between comprehensiveness and intensity of treatment and outcome.These results suggest several important things. First, obesity treatment can be effective and extend beyond the immediate intervention. This is particularly important, because it supports the concept of screening and evaluation of children for overweight and obesity as recommended by the American Academy of Pediatrics8 as a prelude to moving into effective treatment.Second, comprehensive treatment works. Comprehensive treatment was defined as treatment that included (1) counseling for weight loss or healthy diet, (2) counseling for physical activity or physical activity programs, and (3) instruction in and support for use of behavioral management techniques to make and sustain changes in diet and physical activity. This lifestyle approach forms the core of pediatric obesity management and was recommended by the Expert Committee on childhood overweight and obesity published in Pediatrics in 2007.5Third, the level of intensity of intervention was related to outcomes. This becomes important in understanding implementation in practice. High-intensity programs were equivalent to twice-weekly hour-long meetings for 6 months and once-weekly hour-long meetings for the following 6 months with a combination of group and individual sessions with a group of multidisciplinary personnel including dieticians, psychologists, trainers, and physicians.9–11 These interventions correspond with comprehensive multidisciplinary interventions (stage 3 of the expert recommendations5).To put this evidence-based approach into practice will require payment for multidisciplinary care at levels of intensity that corresponds with this proven efficacy.Low-intensity interventions, applicable to primary care settings, used a variety of strategies to achieve results, including structured group models12 that involved a combination of family, parent-only, and child-only instruction,13 the Internet, and social support. The most effective of the low-intensity interventions could be adapted for use as a structured weight-management (step 2)5 approach in primary care. Payment for multidisciplinary personnel and financial support of group treatment models, telephone and Internet care, and mechanisms to support parent-only care interactions, would be critical to allow interventions such as these to be implemented in practice.On the basis of the results of the USPSTF review, it is surprising that the final recommendation was limited to screening and treatment only of children older than 6 years of age. As in the previous USPSTF statement on obesity in 2005, the USPSTF falls short of the mark in not recognizing the developmental trajectory of obesity in childhood. 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 Pediatrics8 and the Expert Committee5 and incorporated into 2009 Healthcare Effectiveness Data and Information Set (HEDIS) (National Committee for Quality Assurance) measures for children aged 2 to 18 years. Pediatricians should continue to screen all children older than 2 years for overweight and obesity by using BMI percentiles and measure weight for length in children younger than 2 years of age. Although stronger evidence will likely continue to emerge, recognition that screening is the first step to individual evaluation and counseling for obesity prevention and treatment should be standard in practice now. Working with families to screen for high-risk nutrition and activity behaviors that contribute to obesity in early childhood must be part of that task. With that said, the current USPSTF report is significant because it provides evidence that obesity treatment can be effective and extend beyond the immediate intervention and that pediatricians in the context of a medical home model that supports multidisciplinary care, with the appropriate supports of training and reimbursement, can provide effective obesity prevention and treatment for the families and children in their care.