The Children with the Bath

Can Primary Care Take Care of Childhood Obesity?

It sounds pretty easy. A pediatrics professor at the University of Gothenburg says primary care can do a fine job treating childhood obesity. In a press release to promote his new publication, Staffan Mårild says:

There’s an attitude that obesity is so terribly difficult to get rid of that you have to send the child to a specialist clinic, sometimes many tens of kilometers away. But the skills are often available closer at hand. And then there’s a greater chance of the treatment taking place.

Supporting his point, his new paper in Acta Paediatrica examines four-year outcomes for two variations on a primary care treatment program. It concludes that they found “significant reductions” in the numbers of children with obesity. BMI scores were down, too.

A Problem with Regression to the Mean

To their credit, the press release concedes the study’s major flaw. It lacks a real control group. In fact, that’s a big problem for claiming effectiveness, all because of something called regression to the mean (RTM).

When you study of sample of individuals who are different from the rest of the population, this issue kicks in. Because on the measure that’s different from the norm, you can be sure that the next time you take the measure again, it will change. It will drift back toward the average of the population.

So if you have a group of kids with more obesity than the rest of the population, you need a control group for testing an intervention. Without it, you can’t be sure that your program has an effect. The same changes might have happened without doing anything. All of the change could be due to RTM.

Oh, and by the way, the sample size was only 64 children.

Inconsistent with a Large Body of Evidence

Certainly, the program that Mårild et al studied might be a fine program. Perhaps a more rigorous study would have proved it works well.

But it is worth noting that the effect claimed in this paper is inconsistent with prior evidence. Mårild’s interventions involved only 12 one-hour visits spread over a year.

In contrast, the USPSTF found that more intensive interventions are required to have an effect on childhood obesity outcomes. The USPSTF analysis found that programs with less than 26 hours of contact are unlikely to be effective.

Perhaps Mårild et al have found the secret sauce for treating childhood obesity in primary care – effectively and less intensively. That would be nice.

But to overturn a body of evidence about the need for intensive treatment, we need real evidence.

Click here for Mårild’s study and here for the press release. For a prior publication on this same study, click here.

The Children with the Bath, painting by Honore Daumier / WikiArt

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November 28, 2018

3 Responses to “Can Primary Care Take Care of Childhood Obesity?”

  1. November 28, 2018 at 11:02 am, Richard Atkinson said:

    Good column, Ted. The idea of treating childhood obesity in a primary care office seems fanciful considering the 1869 papers found in PubMed using the search terms, “diet and exercise and obesity and treatment and children” none of which show a clinically significant long term effect. Papers that purport to show “success” are generally short term or the amount of weight loss or prevention of adiposity progression is small and of questionable clinical significance. I believe this is due to the obsession that childhood obesity can only be treated with diet and exercise. Other serious childhood diseases are treated with drugs and when the stigma surrounding obesity lessens and obesity is considered a “real” disease, we will begin to treat it as a real disease – with drugs. There is insufficient research on drugs in children currently, and that will need to be remedied. To address the question of treatment in a PC office, consider that even if all the pediatricians were to do nothing but treat obesity, we probably don’t have enough due to the sheer numbers of children with obesity. Thus, we are going to have to do a lot more research, develop new treatments, get nurse practitioners and others involved, and most importantly, develop more effective treatments to have any impact on the epidemic.

    • November 29, 2018 at 3:10 am, Ted said:

      Well said. Thanks!

  2. November 30, 2018 at 3:06 pm, Allen Browne said:

    Dr. Atkinson brings up some good points but we need to be careful. Weight loss medications are not a simple solution to the problem. They do not work in isolation. They need to be combined with multidisciplinary treatment including diet, activity, mental health, and environmental issues.