To help children with high BMI, expert panel recommends 26 hours of behavior coaching — but not weight-loss drugs

The US Preventive Services Task Force updated its final recommendations Tuesday for how primary care clinicians can best help children with a high body mass index, the measure most practitioners use to determine whether a person has obesity.

The task force suggested that extensive and intensive behavioral interventions are the best way to help a child get to a healthy weight.

Recent studies have shown that popular weight-loss drugs and surgical procedures are also highly successful treatments for children, and they are recommended as viable options under American Academy of Pediatrics guidelines.

But neither option is part of the USPSTF’s latest recommendations, and along with the large number of hours the task force recommends for behavioral interventions, it has left some doctors frustrated. Several providers characterize the new recommendations as unrealistic or problematic.

What the recommendations say

The latest recommendations from the task force – a volunteer panel of independent medical experts – suggest that clinicians provide intensive behavioral interventions for children who are at least 6 years old with a high BMI, or refer children for such services.

A high BMI for a child is defined a little differently than it is for adults, although both use height and weight to estimate mass. A BMI of 30 or higher is within the obesity range for adults, but a child is considered to have a high BMI if they fall at or above the 95th percentile for their age and sex. That means the child’s BMI is higher than that of 95% of other kids of the same age or gender, based on growth charts from the US Centers for Disease Control and Prevention. Parents can use the CDC’s online calculator to estimate their child’s body fat percentage.

The USPSTF’s recommended interventions can include self-monitoring, goal-setting, supervised physical activity, instruction in healthier eating and limits on screen time. Providers can tailor these options to fit the patient and their family, the task force says, but the interventions should involve at least 26 hours in a calendar year and include supervised physical activity.

According to research that the USPSTF reviewed before making its recommendations, most children who were a part of such intensive programs experienced small weight loss and reductions in BMI after six months to a year. Those who did better spent a larger number of hours with the clinician and had physical activity as a part of their program.

Why the recommendations matter

A high BMI in children can lead to several significant and even life-threatening health conditions including diabetes, breathing issues, bone and joint problems, liver issues, skin problems, high blood pressure and high cholesterol, which itself may lead to heart diseases. Obesity can also make a child a target of bullying, affecting their emotional well-being and self-esteem.

Nearly 20% of children in the US have what’s considered a high BMI. The number of children with obesity has grown significantly, tripling over the past four decades, studies show.

The USPSTF recommendations help primary care providers determine what preventive care works and what doesn’t, and insurance companies use them to help decide what treatments to cover.

The task force gives its guidelines letter grades based on the most up-to-date science. Under the Affordable Care Act, private insurers must cover preventive services that get a grade of A or B; the new child obesity recommendations got a B grade.

Some doctors say guidelines are impractical

Dr. Susma Vaidya, a pediatrician who runs a weight loss clinic at Children’s National Hospital in Washington, says intensive behavioral intervention is essential and important, but she thinks the recommendation of 26 hours per year – which averages out to an hour every other week – is a nearly impossible goal.

“Unfortunately, we don’t have the infrastructure currently to provide this intensive behavioral therapy management,” she said. “It’s very challenging for providers. It’s challenging for parents and for kids to be able to commit to that number of hours. And we know that the amount of BMI improvement can be fairly minimal.”

Dr. Mona Sharifi, an associate professor of pediatrics and biostatistics at the Yale School of Medicine, worked on the American Academy of Pediatrics guidelines that came out last year on helping doctors manage patients with obesity. She was happy to see that the USPSTF recommendations reiterate the strength of the evidence around intensive behavioral treatments, she said, but the group’s last two sets of recommendations on this topic – issued in 2010 and 2017 – were similar, and little has changed.

“Here we are 15 years later from the first version of these, and still, access to this kind of treatment is abysmal – and it might even be worse, really, post-pandemic,” Sharifi said.

Many programs remain inaccessible for the vast majority of children and adolescents who need them most, according to an editorial published alongside the latest guidelines Tuesday in the journal JAMA. Even the past recommendations are “still not routinely implemented in clinical practice,” wrote Dr. Thomas Robinson of the Stanford Solutions Science Lab and Department of Pediatrics and Dr. Sarah Armstrong, a professor of pediatrics and chief of the Division of General Pediatrics and Adolescent Health at Duke University Medical School.

Several highly effective pediatric programs also shut down during the pandemic and still haven’t returned, Sharifi said. Some doctors are trying to resurrect these programs, she said, but “in the absence of appropriate reimbursement from insurers, it’s just been really difficult.”

Dr. Justin Ryder, a pediatric obesity researcher with Stanley Manne Children’s Research Institute at Ann & Robert H. Lurie Children’s Hospital of Chicago, said that such a high benchmark as 26 hours could also mean insurers refuse to cover programs that are less intense.

“I’ve got huge problems with these recommendations,” he said. “I think that these recommendations really do a disservice to kids with obesity.”

Twenty-six hours of intervention is “extraordinarily difficult” to achieve in the clinical setting, he said. “In a primary care setting, it’s almost impossible.”

Lack of recommendations on surgery

Some doctors are also critical of the USPSTF’s decision not to recommend surgery.

Although procedures such as bariatric surgeries are among the options that the American Academy of Pediatrics suggests doctors consider, the task force didn’t review the latest research on the matter, saying surgery is considered “outside the scope of the primary care setting.”

“Bariatric surgery has 10 years of data now in adolescents,” Ryder said. “It has some of the most robust and best long-term followup, as well as outcome data, in this patient population, and to not even mention it as a potential option, it’s a clear miss.”

Lack of recommendations on medication

Some of the biggest disagreements with the recommendation involve weight-loss drugs, for which the USPSTF said “the totality of the evidence was found to be inadequate.”

However, the task force did examine studies involving the medications liraglutide, semaglutide, orlistat, phentermine and topiramate (sold under brand names such as Saxenda, Wegovy, Alli, Lomaira and Topamax, respectively).

In most trials, the medications were associated with larger BMI reductions than with placebos. But there wasn’t enough evidence to determine what effects they could have in the long term, said task force member Dr. John Ruiz, a professor of clinical psychology at the University of Arizona. The drugs also may come with side effects like nausea, vomiting and gallstones.

“There’s just such a limited set of studies done that one doesn’t know if those results are reliable and to whether they are generalizable,” he said. “And whether there’s any harms that have come about, particularly, in longer-term use of those medications. That would be important to know.”

Vaidya says the drugs have transformed her practice in Washington.

“I appreciate that these are children, and we are always very cautious about using medication, but these are FDA-approved medications, and sometimes, these medications facilitate a family or child’s ability to adhere to the lifestyle modifications that we also recommend,” she said.

Vaidya said she has seen children struggle for years to get to a healthy weight through lifestyle interventions alone before they finally get “unstuck” with the help of weight-loss medications.

“I think the role of pharmacotherapy, honestly, can’t be understated,” she said.

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