Experts suggest extended sessions of behavioral coaching for overweight children, up to 26 hours, yet advise against the use of weight-loss medications.
The team proposes that extensive and rigorous behavior modification strategies are the most effective means to assist a child in achieving a healthy body weight.
Rescent findings indicate that well-known weight loss medications and surgical procedures are successful in helping children manage their weight, as per the suggestions of the American Academy of Pediatrics. These options are deemed acceptable under their guidelines.
However, these procedures and drugs are not featured in the US Preventive Services Task Force's (USPSTF) latest recommendations. Moreover, the task force recommends numerous hours for behavioral interventions, which has left some healthcare professionals feeling frustrated and discouraged. Many practitioners question the feasibility of these recommendations.
The recommended guidelines
The USPSTF's recent recommendations, issued by a panel of independent medical experts, suggest that clinicians offer intense behavioral interventions for children aged 6 and above with a significantly high Body Mass Index (BMI). Alternatively, they may refer children for such services.
A child with a high BMI is characterized differently than an adult, using height, weight, and age to determine mass. In children, a BMI of 30 or higher is equivalent to obesity in adults, but a child is considered to have a high BMI if their BMI falls at or above the 95th percentile for their age and gender. This means a child's BMI is higher than that of 95% of their peers of the same age and gender, based on charts from the US Centers for Disease Control and Prevention (CDC). Parents can estimate their child's body fat percentage using the CDC's online calculator.
The USPSTF's recommended interventions may include self-monitoring, goal-setting, supervised physical activity, instruction in healthier eating habits, and limits on screen time. These interventions can be personalized to suit the patient and their family, but they must include supervised physical activity and involve at least 26 hours in a year, according to the task force.
Research reviewed by the USPSTF before making its recommendations shows that most children who participated in such intensive programs experienced small weight loss and reductions in BMI over six months to a year. Those who experienced more significant improvements spent a larger amount of time with the clinician and incorporated physical activity into their program.
The importance of these recommendations
High BMI in children can lead to various severe and potentially deadly health conditions, such as diabetes, breathing difficulties, bone and joint issues, liver problems, skin problems, high blood pressure, high cholesterol (which may lead to heart disease), and increased risk of being bullied.
Currently, around 20% of children in the US have a high BMI. The number of children with obesity has significantly increased over the past four decades, as shown by studies.
The USPSTF recommendations help primary care providers determine which preventive measures are effective and which are not, while insurance companies use them to help decide which treatments to cover.
The USPSTF assigns letter grades to its guidelines based on the latest scientific findings.Under the Affordable Care Act, private insurers must cover preventive services that receive a grade of A or B; the new child obesity recommendations received a B grade.
Some doctors argue the guidelines are unrealistic
Dr. Susma Vaidya, a pediatrician at Children’s National Hospital in Washington who runs a weight loss clinic, believes that intensive behavioral intervention is crucial but thinks the recommendation of 26 hours per year is challenging to achieve.
“Unfortunately, we do not have the infrastructure currently to provide this intensive behavioral therapy management,” she said. “It’s very difficult for providers, parents, and children to commit to that amount of time. And we know that the improvement in BMI can be minimal.”
Dr. Mona Sharifi, an associate professor of pediatrics and biostatistics at the Yale School of Medicine, participated in creating the American Academy of Pediatrics guidelines on managing obesity last year. While she was glad to see that the USPSTF reaffirmed the evidence supporting intensive behavioral treatments, she noted that similar recommendations were issued in 2010 and 2017, with little progress made since.
"Here we are 15 years later from the first version of these recommendations, and still, access to these treatments is poor – and it might even be worse, really, post-pandemic," Sharifi said.
Many programs remain out of reach for most children and adolescents who need them, according to an editorial published alongside the latest guidelines in the journal JAMA. Such programs are "still not routinely implemented in clinical practice," wrote Dr. Thomas Robinson of the Stanford Solutions Science Lab and Dr. Sarah Armstrong, a professor of pediatrics and head of the Division of General Pediatrics and Adolescent Health at Duke University Medical School.
Several highly effective pediatric programs have shut down during the pandemic and have not yet resumed, Sharifi stated. Some doctors are making efforts to reestablish these programs, but "in the absence of appropriate reimbursement from insurers, it has been incredibly tough."
Dr. Justin Ryder, a pediatric obesity researcher at Stanley Manne Children’s Research Institute at Ann & Robert H. Lurie Children’s Hospital of Chicago, pointed out that such a high benchmark as 26 hours could result in insurers not covering less intense programs.
“I have significant problems with these recommendations,” he said. “I believe that these recommendations truly do a disservice to children with obesity.”
Twenty-six hours of intervention is "exceptionally hard" to achieve in a clinical setting, he said. "In a primary care setting, it's practically impossible."
Critics assail the USPSTF's decision to shun surgery, specifically bariatric surgeries, as a viable option, despite the American Academy of Pediatrics advocating for it. The task force, however, overlooked the latest research on the topic, labeling surgery as beyond the realm of regular care.
"Bariatric surgery has clocked a decade of data in adolescents," asserted Ryder. "It boasts some of the most extensive and promising long-term follow-up, alongside outcome data, in this age group. To neglect mentioning it as a potential solution is egregious oversight."
Disagreement over weight-loss meds
The recommendation faces significant opposition, particularly over weight-loss drugs, which USPSTF deemed the available evidence insufficient. Nevertheless, the task force scrutinized trials on medications like liraglutide, semaglutide, orlistat, phentermine, and topiramate—drugs marketed under brands such as Saxenda, Wegovy, Alli, Lomaira, and Topamax.
In most trials, these medications were linked to higher BMI reductions compared to placebos. However, the task force acknowledged a lack of evidence to foresee the drugs' long-term effects. Furthermore, the medications were associated with adverse effects like nausea, vomiting, and gallstones.
According to task force member Dr. John Ruiz, a professor of clinical psychology at the University of Arizona, the scarcity of studies limits the reliability and applicability of the findings. Moreover, the long-term effects, including potential harm, of these medications remain unknown.
Vaidya insists the drugs have revolutionized her practice in Washington.
"While we're always mindful of children and medications, these drugs are FDA-approved, and they aid families and children in adhering to the lifestyle modifications we advise," she said.
Vaidya revealed that she has encountered children battling weight issues for years without success until medications stepped in to facilitate weight loss.
"The influence of pharmaceuticals in this context can't be overstated," she said.
