Behavioral Therapy, Not Weight-Loss Drugs, Experts Say

The US Preventive Services Task Force (USPSTF) updated its recommendations in June for how primary care clinicians can effectively assist children with high body mass index (BMI), a standard metric used to identify obesity. The task force emphasized that extensive and intensive behavioral interventions are the most effective means for helping children achieve a healthy weight.

Although recent studies have highlighted the success of weight-loss drugs and surgical procedures for children, and the American Academy of Pediatrics endorses these methods as viable options, they are not included in the USPSTF’s current recommendations. The task force’s call for a significant number of hours dedicated to behavioral interventions has frustrated some healthcare providers, who find these guidelines unrealistic or problematic.

Recommendations overview

The latest recommendations from the USPSTF — a volunteer panel of independent medical experts —advise clinicians to offer intensive behavioral interventions to children aged six and older with a high BMI or to refer them to such services.

BMI for children is calculated differently than for adults, though both use height and weight to estimate mass. For adults, a BMI of 30 or higher indicates obesity, whereas for children, a high BMI is defined as being at or above the 95th percentile for their age and sex. This means a child’s BMI is higher than 95% of peers of the same age and gender, according to CDC growth charts. Parents can use the CDC’s online calculator to estimate their child’s body fat percentage.

The USPSTF’s recommended interventions include self-monitoring, goal-setting, supervised physical activity, instruction in healthier eating, and limits on screen time. These interventions should be tailored to fit the patient and their family and should involve at least 26 hours per year, including supervised physical activity.

Research reviewed by the USPSTF indicates that children in intensive programs typically experience modest weight loss and BMI reduction within six months to a year. Greater success was noted in those who spent more time with clinicians and included physical activity in their regimen.

Significance of the recommendations

High BMI in children can lead to severe and potentially life-threatening health issues, such as diabetes, respiratory problems, bone and joint issues, liver conditions, skin problems, high blood pressure, and high cholesterol, which can lead to heart disease. Obesity also exposes children to bullying, affecting their emotional well-being and self-esteem.

Approximately 20% of US children have a high BMI, with obesity rates tripling over the past four decades. The USPSTF recommendations guide primary care providers on effective preventive care, influencing insurance coverage decisions. Under the Affordable Care Act, preventive services graded A or B by the task force must be covered by private insurers; the new child obesity recommendations received a B grade.

Practical challenges

Dr. Susma Vaidya, a pediatrician running a weight loss clinic at Children’s National Hospital in Washington, acknowledges the importance of intensive behavioral intervention but views the 26-hour annual recommendation as impractical. She said:

“We lack the infrastructure to provide such intensive therapy,” noting the challenges for providers, parents, and children in committing to this time frame, which may only yield minimal BMI improvements.

Dr. Mona Sharifi, an associate professor at Yale School of Medicine, who contributed to the American Academy of Pediatrics guidelines on managing childhood obesity, appreciates the emphasis on behavioral treatments. However, she notes that little progress has been made since the 2010 and 2017 recommendations, and access to these treatments remains poor, possibly worsened by the pandemic.

Lack of surgical recommendations

Some doctors also criticize the USPSTF’s decision not to include surgical options. Despite the American Academy of Pediatrics considering bariatric surgery a viable option, the task force did not review the latest research, viewing surgery as outside the primary care scope.

Medication recommendations

The USPSTF also refrained from recommending weight-loss drugs, citing insufficient evidence. While studies on medications like liraglutide, semaglutide, orlistat, phentermine, and topiramate showed larger BMI reductions compared to placebos, long-term effects and potential harms remain unclear, according to task force member Dr. John Ruiz.

Dr. Vaidya argues that these FDA-approved medications have transformed her practice, helping children who struggled with lifestyle interventions alone. “The role of pharmacotherapy cannot be understated,” she said, noting that these drugs can facilitate adherence to lifestyle modifications.

And pharma companies agree

Companies producing popular weight loss injections like Ozempic and Mounjaro are beginning to test versions for children as young as six years old who struggle with obesity.

Eli Lilly announced its intention to start clinical trials with Mounjaro for children aged 6-11. Novo Nordisk, the maker of Ozempic, reported it is in phase three of testing Saxenda, a version of its drug for children aged 6-12.

However, experts stress that lifestyle and behavior modifications should be the primary focus of treatment. The weight loss injections can cost up to $1,500 and may not be covered by insurance. The studies are expected to span several years.

Your responses and feedback are welcome!

Source: “To help children with high BMI, expert panel recommends 26 hours of behavior coaching — but not weight-loss drugs,” CNN, 6/18/24
Source: “Ozempic, Mounjaro manufacturers testing weight loss drugs for kids,” MSN, undated
Image by Food Photographer | Jennifer Pallian on Unsplash

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About Dr. Robert A. Pretlow

Dr. Robert A. Pretlow is a pediatrician and childhood obesity specialist. He has been researching and spreading awareness on the childhood obesity epidemic in the US for more than a decade.
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Dr. Pretlow’s invited presentation at the American Society of Animal Science 2020 Conference
What’s Causing Obesity in Companion Animals and What Can We Do About It

Dr. Pretlow’s invited presentation at the World Obesity Federation 2019 Conference:
Food/Eating Addiction and the Displacement Mechanism

Dr. Pretlow’s Multi-Center Clinical Trial Kick-off Speech 2018:
Obesity: Tackling the Root Cause

Dr. Pretlow’s 2017 Workshop on
Treatment of Obesity Using the Addiction Model

Dr. Pretlow’s invited presentation for
TEC and UNC 2016

Dr. Pretlow’s invited presentation at the 2015 Obesity Summit in London, UK.

Dr. Pretlow’s invited keynote at the 2014 European Childhood Obesity Group Congress in Salzburg, Austria.

Dr. Pretlow’s presentation at the 2013 European Congress on Obesity in Liverpool, UK.

Dr. Pretlow’s presentation at the 2011 International Conference on Childhood Obesity in Lisbon, Portugal.

Dr. Pretlow’s presentation at the 2010 Uniting Against Childhood Obesity Conference in Houston, TX.

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