Interventions for Children and Adolescents With High Body Mass Index—Implementing the Recommendations in Clinical Practice

The pediatric obesity epidemic continues to assail our nation’s youth, with 1 in 5 children and adolescents affected by obesity, based on 2020 data from the Centers for Disease Control and Prevention.¹ Given the metabolic disease burden associated with pediatric obesity, clinical and research endeavors to identify evidence-based interventions continue at a rapid pace. Data regarding intensive lifestyle therapy (ILT), pharmacotherapy, and bariatric surgery interventions^2,3 have changed the landscape of treatment for pediatric patients in the past decade. In the past 4 years specifically, we have seen a rapid increase in pharmacotherapy options approved by the US Food and Drug Administration (FDA) for pediatric weight management. As a result, clinicians treating youth with obesity, both in primary and tertiary care, continue to look to professional organizations for how and when to utilize newer therapeutic options.

The United States Preventive Services Task Force (USPSTF) reassessed their 2017 recommendations on management of high body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) (≥95th percentile) among children and adolescents. In their updated 2024 statement, the USPSTF reaffirmed the importance of comprehensive ILT targeting pediatric obesity in children aged 6 years and older stating with moderate certainty that these interventions have a moderate net benefit (grade B statement).^4,5 Screening for obesity with BMI calculations was removed from recommendation, as it is now a routine part of clinical care. Furthermore, the recommendation reaffirmed the need for contact between patients and ILT practitioners to be frequent, with the data supporting at least 26 contact hours over 3 to 12 months.^4,5 The USPSTF found inadequate evidence on the benefits of pharmacotherapy in youth with obesity, encouraging clinicians to use ILT as the primary intervention.^4,5

Twenty-six contact hours of ILT equates to weekly, 1-hour sessions for 6 months.⁶ The evidence supports that, in general, the more contact hours, the better the weight outcomes. While ILT with at least 26 contact hours is associated with significant improvement in BMI (mean BMI difference,−0.8; 95% CI, −1.2 to −0.4), interventions with at least 52 contact hours are associated with a stronger and more consistent BMI reduction (mean BMI difference, −2.0; 95% CI, −4.0 to −0.1).^4,5 Identification of the necessary dose to improve outcomes is tremendously helpful in setting the bar for clinicians and families. However, this number can also be disheartening, given the limited capacity of staff, resources, and funding in clinical programs. How can health care practitioners supplement clinical care to meet this 26-hour threshold? The key may be the physical activity component. The inclusion of physical activity sessions during behavioral intervention studies was associated with significantly greater reductions in BMI, as stated in the USPSTF evidence review.^4,5 These sessions varied in frequency (1-2 times per week), intensity, and type. Given the variability in sessions within studies, athletics participation could be prescribed by weight management practitioners to bridge the gap between clinical care and the 26-hour threshold. For those not interested in group sports or hindered by participation fees, collaborative programming with local community organizations, like the YMCA (eg, FUN2BFIT program) or the Boys & Girls Club, could be arranged. The inability to attain 26 hours should not deter patients or practitioners from participating in, referring to, or implementing obesity interventions. Rather, clinical teams and families should work together to maximize intervention dose using clinical and community programs synergistically.

In the updated USPSTF recommendations,^4,5 there is a reinforcement to intervene at a young age when pediatric obesity is identified, with ILT recommended as early as age 6 years. Earlier intervention is better to establish healthy habits early in a child’s development,⁷ to intervene prior to puberty (when long-term cardiometabolic risk increases),⁸ and to prevent psychosocial morbidity.² Establishing referrals to ILT at age 6 years as a standard of care has the potential for significant impact on weight trajectories of our nation’s youth. However, evidence supports that weight patterns develop early in life, suggesting there could be benefit to starting interventions earlier than age 6 years. A prospective analysis of a population-based sample of 51 505 children found that approximately 90% of children who had obesity at age 3 years continued to have an elevated BMI in adolescence.⁹ The greatest acceleration in BMI occurred between ages 2 and 6 years. For many young children and their families, intervention in the primary care setting that is less intensive may be adequate. However, for others, especially those with class 2 (BMI ≥120% to <140% of the 95th percentile) and class 3 (BMI ≥140% of the 95th percentile) obesity at an early age, further evaluation and ILT through a tertiary weight management program may be indicated. The absence of the inclusion of children younger than age 6 years in the USPSTF recommendation should not be seen as a reason to wait to refer or initiate treatment: it simply means that additional studies are needed to make an evidence-based recommendation. That said, 20 of the behavioral trials in the USPSTF evidence review^4,5 included children younger than 6 years, and 7 trials targeted preschool- to kindergarten-aged children specifically. Children and young adults ages 2 to 19 years participating in these behavioral interventions demonstrated a 0.7 greater reduction in BMI than those in control groups after 6 to 12 months.^4,5 Effect modification was not detected by age category (preschool, elementary, adolescent, wide range). Additionally, no behavioral trials reported increased risk of issues with self-esteem, body satisfaction, or disordered eating by participating.^4,5 As such, when weighing the risks vs benefits for our youngest patients, we should err on the side of medical beneficence and initiate ILT early when the medical history and anthropometrics indicate concern.

Lastly, the USPSTF found inadequate evidence on the benefits of pharmacotherapy in children or adolescents with pediatric obesity. This statement was made after reviewing the evidence of current FDA-approved anti-obesity medications (AOMs) in adolescents: orlistat, liraglutide, semaglutide, and phentermine and topiramate.^4,5 The recommendations acknowledge that the newly available data on these AOMs was sufficient to allow for FDA approval of liraglutide (2020),¹⁰ semaglutide (2022),¹¹ and phentermine and topiramate (2022)¹² in adolescents aged 12 years and older, given each of these AOMs had larger effects on weight compared with ILT alone. However, the USPSTF identified weight plateau with medications, weight rebound after medication discontinuation, and only temporary weight loss as downfalls of pharmacotherapy. If medications need to be used long-term to maintain weight loss, the USPSTF states that long-term studies of both efficacy and harms are essential. This sentiment is undoubtably shared by the medical community, ie, the need for additional data to characterize long-term safety, with a focus on outcomes in the years of prime development. However, it should be recognized that the recommendations on AOM use differ across medical societies. In 2023, the American Academy of Pediatrics (AAP) recommended: “Pediatricians and other pediatric health care providers should offer adolescents 12 years and older with obesity (BMI ≥ 95th percentile) weight loss pharmacotherapy, according to medication indications, risks, and benefits, as an adjunct to health behavior and lifestyle treatment.”² The differences in between USPSTF and AAP recommendations can be attributed to underlying methodology. The AAP bases recommendations on evidence-based literature and includes expert opinion, clinical guidelines, and position statements from professional societies when necessary. The USPSTF purely uses the evidence-based literature, although USPSTF acknowledges that clinical decisions involve more considerations than evidence alone, stating “Clinicians should understand the evidence but individualize decision-making to the specific patient or situation.”^4,5 As such, the updated USPSTF recommendations do not prohibit health care practitioners from using AOMs. So the question remains: do AOMs have a role in pediatric patients with high BMI? The answer should be based on the individual patient profile, including age, BMI, BMI trajectory, current metabolic comorbidities, family history, and patient response with prior ILT. A detailed assessment and longitudinal practitioner-patient care will help patients and families make informed decisions about whether and when to initiate AOM, which we now know is associated with improved weight loss compared with ILT alone. Health care practitioners can turn to organizations, like the Obesity Medicine Association, to access clinical practice guidelines on the use of AOMs in the pediatric population for further direction on choice of agent, dosing, monitoring parameters, and safety information.¹³

The time to prevent and intervene on childhood obesity is now, and the need to start with ILT is clear. However, it is critical to continue to optimize interventions for each patient. For many patients, ILT alone may not be enough to prevent serious outcomes. In these instances, pharmacotherapy and/or bariatric surgery may need to be considered to improve health outcomes in youth with obesity.

Published: June 18, 2024. doi:10.1001/jamanetworkopen.2024.18201

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2024 Kharofa RY et al. JAMA Network Open.

Corresponding Author: Amy S. Shah, MD, MS, Division of Endocrinology, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH ([email protected]).

Conflict of Interest Disclosures: Dr Kharofa reported receiving grants from Rhythm Pharmaceuticals outside the submitted work. No other disclosures were reported.