The USPSTF recommends (grade B) that we screen all kids older than 6 years for obesity. Their recommendation is evidence-based and well-thought out. But it’s still a problem, says a new editorial at JAMA Internal Medicine. They have a point. As I’ve discussed before, there are four questions I always consider, which I adapted from David Sackett’s classic handbook on evidence-based medicine:
- Is the condition prevalent and severe enough to warrant screening?
- Do we have a cost-effective means to screen the general population?
- Does early diagnosis make a difference (that is, do we have treatments available that are more successful when patients are diagnosed earlier?)
- Will an early diagnosis motivate people to use information gained from screening?
(1) and (2) are no-brainers. Obesity is prevalent, and it’s super-cheap to measure. The problems kick in with (3) though. Even (4) is a problem, as it’s hard to imagine that telling people they’re obese is what makes a difference in their doing something to help. From the editorial:
The benefit of treatment for obesity is clear… The specific treatments recommended are “comprehensive, intensive behavioral interventions” that are multicomponent and incorporate activities such as counseling children and their families regarding nutrition, physical activity, and techniques to help change behavior through self-monitoring, goal setting, and problem solving. Based on growth in the evidence base, including the quality of studies, the recommendations are more far-reaching and specific than in 2010. For the 2017 recommendation, the USPSTF incorporated results from 42 trials with multicomponent behavioral interventions involving nearly 7000 children. These trials included 8 rated as “good quality.” However, only about one-quarter of these studies included adolescents, limiting inferences about this group. Screening is still recommended, using age- and sex-specific BMI, as are obesity treatment programs that provide at least 26 contact hours; contact hours were calculated based on the number and length of intervention sessions. Evidence points to a dose response of treatment, with the greatest success achieved by programs with at least 52 contact hours (7 trials tested interventions of this length). These longer-duration programs have clear evidence of improvements in weight status and some related cardiometabolic risk factors after 6 or 12 months of follow-up. The findings on cardiometabolic risk factors are notable considering that sustained improvements early in life will likely have long-term benefits in preventing diabetes and metabolic diseases in adulthood.
Who is going to pay for these interventions? How will we get people the support they’ll need to get kids to them? Who will actually do these interventions on a nationwide scale? All important questions, and we continue to talk about raising cost-sharing and skimping back on benefits, I doubt that these programs will be top of the list for plans.
It’s not enough to screen and point out the problem. We also have to have solutions available to people once we’ve told them they need to do something.
We also could massively focus on prevention, which might make a lot of this moot.