Illustrative case
A 10-year-old boy comes in with his mother for a well-child check-up. His BMI is 40 kg/m2—above the 99th percentile for his age and up from 37 a year ago. His blood pressure is 120/84 mm Hg. What treatment, if any, should you offer for his obesity?
Childhood obesity is a global epidemic. In the United States, 19.6% of children ages 6 through 11 and 18.1% of 12- to 19-year-olds are obese, a 3-fold increase in the last 30 years.3 Without intervention, most obese adolescents will become obese adults, threatening to reverse the progress in slowing cardiovascular morbidity and mortality that has occurred over the past few decades.3
Obese kids get adult diseases
Obesity is a risk factor for a variety of chronic conditions, including cardiovascular disease, cerebrovascular disease, and arthritis. Severe obesity is also associated with higher mortality rates.4 Unfortunately, these comorbidities are not limited to adulthood.
“Adult” diseases, such as obstructive sleep apnea, dyslipidemia, and type 2 diabetes, are increasingly seen in children and adolescents.1 Nutritional deficits such as vitamin D and iron deficiency are often seen in obese children, as well.5 There are also psychological ramifications of childhood obesity, including social isolation and depression.6
The USPSTF recently upgraded its recommendation regarding obesity screening in children ages 6 and older from I (insufficient evidence) to B (a positive grade based on high or moderate certainty of the benefit of the intervention), citing new evidence in favor of screening and treating or referring children when appropriate.2 The systematic review we report on here, which formed the basis for the USPSTF’s upgrade, focused on management options for children identified as overweight or obese.
STUDY SUMMARY: Intense, comprehensive efforts pay off
This systematic review1 included studies of children ages 4 to 18 years who were overweight (defined as a body mass index [BMI] in the 85th to 94th percentile for age and sex) or obese (either a BMI at or above the 95th percentile for age and sex or a BMI >30 kg/m2). The researchers found 25 trials—15 of behavioral interventions alone and 10 that combined behavioral and pharmacologic interventions—that met their criteria: The studies focused on weight loss and/or maintenance, reported outcomes ≥6 months from baseline, and were conducted (or feasible) in a primary care setting.
Behavioral interventions were categorized by treatment intensity (as measured by hours of contact, which ranged from <10 hours to >75) and comprehensiveness (including nutritional counseling, physical activity counseling or participation, and counseling on behavioral management techniques). Weight outcomes were categorized as short-term (6-12 months since treatment initiation) or maintenance (≥12 months after the end of active treatment).
The 15 behavioral intervention trials included 1258 children ages 4 to 18 years, most of whom were obese. Most trials were small and reported high retention rates. All had beneficial effects on weight in the intervention group compared with the controls, but not all changes were statistically significant. Higher intensity and more comprehensive programs had better outcomes.
The largest effects were in 3 moderate- to high-intensity, comprehensive weight management programs with ≥26 hours of contact. These 3 trials demonstrated a difference in BMI of 1.9 to 3.3 in the intervention groups at 12 months compared with the controls. (A 3.3 difference in BMI is equal to approximately 13 lb in an 8-year-old and 17 lb in a 12-year-old.)
Four behavioral intervention studies reported outcomes ≥12 months after completing the intervention (range 15-48 months). Three of the 4 reported continued beneficial effects on weight after the active treatment period, but the effects were markedly attenuated.
The only adverse effect reported in the trials of behavioral interventions was the injury rate among children in an exercise program, but it was minimal: One fracture was reported, vs no injuries for the controls. No differences were reported in height, eating disorders, or depression. However, fewer than half of the behavioral intervention trials reported on adverse effects.