Archivos para 9 febrero 2010

USPSTF Recommends Obesity Screening for Children Ages 6 to 18 Years


January 21, 2010 — The US Preventive Services Task Force (USPSTF) recommends that clinicians screen children ages 6 to 18 years for obesity and refer as appropriate to programs to improve their weight status, according to evidence-based guidelines posted online January 18 and to be published in the February print issue of Pediatrics. The statement, which is an update of the 2005 USPSTF statement about screening for overweight in children and adolescents, is accompanied by a supporting systematic review and commentary. “Since the 1970s, childhood and adolescent obesity has increased three- to sixfold,” write chair Ned Calonge, MD, MPH, from the Colorado Department of Public Health and Environment in Denver, and colleagues from the USPSTF. “Approximately 12% to 18% of 2- to 19-year-old children and adolescents are obese (defined as having an age- and gender-specific BMI [body mass index] at >95th percentile)….Previously, the USPSTF found adequate evidence that BMI was an acceptable measure for identifying children and adolescents with excess weight.” The USPSTF evaluated evidence for the efficacy of pediatric weight management interventions that are feasible in primary care or referable from primary care. The task force also considered the evidence for the magnitude of potential harms of treatment in children and adolescents. USPSTF Screening Recommendation This evidence led the USPSTF to issue a grade B recommendation that clinicians screen children 6 years and older for obesity and provide obese children with intensive counseling and behavioral interventions designed to improve weight status, or that they refer them for such counseling and interventions. During health maintenance visits, height and weight are routinely measured, allowing calculation of BMI. Based on a review of 20 clinical trials of behavioral and pharmacologic interventions for obesity, the task force concluded that evidence was adequate that comprehensive, moderate- to high-intensity interventions effectively improve BMI in children. “Over the past several years, research into weight management in obese children and adolescents has improved in quality and quantity,” write Evelyn P. Whitlock, MD, MPH, from the Center for Health Research, Kaiser Permanente in Portland, Oregon, and colleagues. “Despite important gaps, available research supports at least short-term benefits of comprehensive medium- to high-intensity behavioral interventions in obese children and adolescents.” Moderate- to high-intensity programs are defined as those in which there are more than 25 hours of contact with the child and/or family during a 6-month period. Low-intensity interventions were not associated with significant improvement in weight status. Three components needed for effective, comprehensive programs are counseling regarding healthy diet and/or weight loss; counseling regarding physical activity recommendations or a physical activity program; and behavioral management techniques including setting goals and self monitoring. Families seeking treatment for obese children should therefore consider comprehensive programs targeting weight control through healthy food choices, physical exercise, and building behavioral skills. The task force also concluded that evidence is adequate that the harms of behavioral interventions are no greater than small, and that there is moderate certainty that the net benefit is moderate for screening for obesity in children at least 6 years old and for offering or referring children to moderate- to high-intensity interventions to improve weight status. The USPSTF did not find sufficient evidence for screening children younger than 6 years. Although interventions that combined pharmacotherapy (sibutramine or orlistat) with behavioral interventions were associated with modest short-term improvement in weight status in children at least 12 years old, there were no long-term data on maintenance of improvement after medications were discontinued. The magnitude of the harms of these medications in children could not be estimated with certainty, but known adverse effects include elevated heart rate and blood pressure and adverse gastrointestinal tract effects. “Areas for further research include investigations to determine the specific effective components of behavioral interventions,” the task force concludes. “Longer-term follow-up of participants in behavioral or multicomponent trials is needed to confirm maintenance of treatment effect and to assess longer-term risks and harms. Investigation is needed of more efficient, primary care–feasible interventions that use allied health professionals. More studies are needed that address weight management in minority children and adolescents, behavioral interventions in younger children (aged <5 years), and behavioral interventions in children who are overweight but not obese.” Recommendations Supported by American Academy of Pediatrics In an accompanying commentary, pediatrician and American Academy of Pediatrics Board of Directors member Sandra Hassink, MD, FAAP, from A. I. Dupont Hospital for Children in Wilmington, Delaware, notes that the American Academy of Pediatrics supports the USPSTF recommendations but also recommends routine obesity screening of children beginning at age 2 years. “Recognition that screening is the first step to individual evaluation and counseling for obesity prevention and treatment should be standard in practice now,” Dr. Hassink writes. “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.” The statement, review, and commentary authors have disclosed no relevant financial relationships. Pediatrics. Published online January 18, 2010. Clinical Context The USPSTF 2005 guidelines for screening and interventions for overweight children recommended use of BMI to identify overweight children. There was inadequate evidence to recommend weight management intervention. A systematic review by Whitlock and colleagues in the January 18, 2010, online issue of Pediatrics assessed the benefits and harms of behavioral and pharmacologic interventions for overweight and obese children. This statement updates the 2005 USPSTF recommendation statement on screening for overweight in children and adolescents. Study Highlights The review of the literature included Ovid Medline, PsycINFO, the Education Resources Information Center, the Database of Abstracts of Reviews of Effects, the Cochrane databases, reference lists, and expert recommendations. Age- and sex-specific BMI percentile is preferred for identification of children with excess weight. Overweight is defined by age- and sex-specific BMI at 85th to 94th percentile. Obesity is defined by age- and sex-specific BMI at 95th percentile or higher. Children 6 years or older should be screened. Insufficient evidence exists for screening children younger than 6 years. Appropriate screening interval could not be determined. 13 behavioral intervention trials with 1258 overweight or obese children aged 4 to 18 years were reviewed. Treatment intensity was classified by hours of contact at a 6-month period as very low (< 10 hours), low (10 – 25 hours), moderate (26 – 75 hours), or high (> 75 hours). Weight outcomes were defined as short term (6 – 12 months after beginning of intervention) or maintenance (1 – 4 years after beginning of intervention and at least 1 year after end of intervention). Comprehensive interventions included dietary counseling for weight loss or healthy diet, physical activity counseling or program, and behavioral management instruction and support. The recommended intervention is to refer or offer patients comprehensive moderate- to high-intensity programs at specialty facilities. Moderate- to high-intensity intervention programs resulted in modest weight changes for up to 12 months. Moderate- to high-intensity interventions result in possible improvement in insulin-resistance measures but an inconsistent reduction in cardiovascular risk factors. Low-intensity interventions did not significantly improve weight status. The US Food and Drug Administration approved sibutramine, a centrally acting appetite suppressant, for children 16 years and older and orlistat, a lipase inhibitor, for children 12 years and older. 7 trials with 1294 obese children aged 12 to 18 years assessed combined pharmacologic and behavioral interventions: In 691 subjects, 6 to 12 months of sibutramine plus behavioral intervention vs placebo plus behavioral intervention resulted in a BMI improvement of 1.6 to 2.7 kg/m2. In 539 subjects, 12 months of orlistat plus behavioral intervention vs behavioral intervention alone resulted in a BMI improvement of 0.85 kg/m2. Maintenance effects after discontinuation of pharmacologic agents are unknown. The results of intervention on overweight children are not known. Weight management programs had no adverse effects on growth, eating disorder pathology, or mental health and minimal risk for exercise-induced injury. Serious adverse effects occurred in 2.7% of patients taking sibutramine vs less than 1% of patients taking placebo. Adverse effects of sibutramine included elevated heart rate, elevated blood pressure, and mild to moderate gastrointestinal tract symptoms. Adverse effects occurred in 3% of patient taking orlistat vs 2% of those taking placebo. Surgical treatments and obesity prevention were not addressed in this statement. Clinical Implications The USPSTF recommends screening children 6 years and older for obesity, defined as age- and sex-specific BMI at the 95th percentile or higher. The USPSTF recommends offering or referring obese children for comprehensive moderate- to high-intensity programs with dietary, physical activity, and behavioral counseling components

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