The USPSTF recommend clinicians refer children and adolescents 6 years or older with a high BMI to intensive behavioral interventions

By Priyanjana Pramanik, MSc.Reviewed by Danielle Ellis, B.Sc.Jun 21 2024

In a recent statement published in JAMA, researchers at the US Preventive Services Task Force (USPSTF) discussed the high prevalence of obesity among adolescents and children in the US, particularly among certain ethnic groups and those from lower-income families.

This recommendation updates the 2017 USPSTF statement on screening for obesity in adolescents and children aged six years or older. Experts now recommend that clinicians provide or refer patients aged six years and older presenting with a high body mass index (BMI) to comprehensive, intensive behavioral interventions.

Background

Nearly 20% of US adolescents and children between the ages of 2 and 19 have a BMI either at or more than the 95th percentile for their sex and age, as per growth charts by the Centers for Disease Control (CDC) from 2000.

This prevalence rises with age and is particularly pronounced among Native American/Alaska Native, non-Hispanic Black, and Hispanic/Latino children, as well as those belonging to lower-income households.

The USPSTF reviewed the evidence on pharmacotherapy and behavioral counseling interventions for weight management or weight loss that can be referred to or provided from primary care settings. Surgical weight loss interventions were not included.

Fifty randomized clinical trials (RCTs) with 8,798 participants examined behavioral interventions, showing significant reductions in BMI and improvements in quality of life and cardiometabolic risk factors. Eight trials assessed pharmacotherapy, with medications like semaglutide and phentermine/topiramate showing significant BMI reductions but with notable side effects.

The benefit of behavioral interventions

Based on the review findings, the USPSTF determined with a moderate level of certainty that intensive and comprehensive behavioral interventions provide a moderate net benefit for adolescents and children aged six years and above with high BMIs. These interventions should be provided, or patients should be referred to appropriate healthcare professionals.

Behavioral interventions led to significant reductions in BMI and improvements in quality of life and cardiometabolic risk factors. High-contact interventions (≥26 hours) were particularly effective.

Specifically, behavioral interventions involving 26 contact hours or more over a year, including physical activity with supervision, showed results such as significant weight loss and improvements in cardiometabolic risk factors.

These interventions often involve multidisciplinary teams and include supervised physical activity sessions, information on safe exercising and healthy eating, and techniques for behavior change such as monitoring activity and diet, goal-setting, and problem-solving.

Studies have shown these interventions reduce BMI and weight and improve quality of life and cardiometabolic outcomes. For example, high-intensity interventions have shown a 1.4-point reduction in BMI and improvements in blood pressure and fasting plasma glucose levels.

Families face barriers to accessing these interventions. The USPSTF acknowledges the stigma linked to high BMI but found no evidence that the recommended behavioral interventions increase stigma or related harms and can improve quality of life and self-esteem.

Pharmacotherapy interventions

Evidence for pharmacotherapy in adolescents and children is limited. Medications like liraglutide, semaglutide, orlistat, and phentermine/topiramate have shown higher weight loss compared to a placebo.

For example, semaglutide showed a 6.0-point greater reduction in BMI after 16 months. However, long-term maintenance of weight loss post-medication is not well-documented, and gastrointestinal side effects are common. For this reason, the USPSTF recommends prioritizing behavioral interventions over pharmacotherapy.

Resources for clinicians and families

The recommendation referred to several resources that are available to support clinicians and families, including guidelines from the Community Preventive Services Task Force, the Department of Health and Human Services, and the CDC.

The USPSTF also references related recommendations to screen for diabetes, lipid disorders, and high blood pressure in children and adolescents.

Conclusions

The USPSTF recommends that clinicians provide or refer adolescents and children aged six or older presenting with high BMIs to intensive and comprehensive behavioral interventions. These interventions, involving multiple components and at least 26 contact hours, are effective in reducing BMI and improving cardiometabolic risk factors.

Pharmacotherapy, while showing promise in weight reduction, has limited evidence and potential harms; thus, it should not be the primary intervention.

Medications showed larger reductions in BMI but were associated with moderate harms, primarily gastrointestinal issues. The evidence for the long-term benefits and harms of pharmacotherapy is limited.

In comparison, behavioral interventions showed no increase in adverse events, including disordered eating or decreased self-esteem. Pharmacotherapy, while effective for weight loss, showed moderate harm related to gastrointestinal symptoms.

Addressing childhood obesity requires a multifaceted approach, incorporating behavioral counseling, community support, and systemic changes to mitigate health inequities.

Further research is needed to identify effective interventions for children younger than six years and to explore the long-term effects of both pharmacotherapy and behavioral interventions.