Following a Failing Script in Childhood Obesity

The script is clear enough. Childhood obesity is a “serious and growing concern.” Its effects can be “devastating,” say the authors of a recent commentary on USPSTF guidelines for it. So the script from the USPSTF tells pediatricians that they should screen for obesity starting at the age of six and refer children to behavioral therapy based on that screening. In the abstract that makes sense. But in the real world that script is failing for families and youth living with childhood obesity.

In short, it’s failing because it’s impractical. Most families can’t access real, intensive behavior therapy. The programs are few and far between. Health insurance most often doesn’t pay for them. But it’s also failing because behavioral therapy alone is profoundly inadequate for children experiencing the effects of clinically significant obesity.

The USPSTF is on course to update its 2017 recommendations for childhood obesity. Though we have real doubts that it will come any closer to helping children and families in the real world, we would love to be proven wrong.

A Non-Starter in the Real World

So consider the typical case of a child with obesity seeing his pediatrician. Hunter Jackson Smith and colleagues tell us that David is a 10-year-old from a small rural town. His doctor finds the signs and symptoms of obesity. So she recommends intensive behavioral therapy (as USPSTF says she should) to help David manage the condition. Unfortunately, the closest center delivering these services is 75 miles away. Both parents work full time jobs and David needs to keep up with school work. So David and his father go home with some information on diet and exercise. All this adds up to a DIY approach to obesity that will have a nil effect.

Except that perhaps, David will get the message that something is wrong with him.

Impractical and Ineffective

Claudia Fox and Aaron Kelly are co-directors of one of the relatively few centers in the U.S. that deliver the full range of effective medical care for pediatric obesity. It is the Center for Pediatric Obesity Medicine at the University of Minnesota. Kelly tell us:

“The 2017 USPSTF recommendation is impractical for most families. Even for the small fraction of patients/families who have access to this type of care and have the resources to follow the recommendation, this single-dimension treatment approach is woefully inadequate.”

So we are glad that the USPSTF is revisiting those largely ineffective 2017 recommendations. But unfortunately, the script for their work still seems rooted in a false belief that obesity is mostly a problem of bad behavior. It ignores guidance from the American Academy of Pediatrics on the value of metabolic and bariatric surgery for preventing the complications of obesity in young persons.

Focusing on the Wrong Questions

So long as the USPSTF focuses on questions about how behavioral therapy can fix this biological problem, they will keep coming up with utterly ineffective recommendations. The unmet need is great, but unfortunately, USPSTF is not on track to address it.

Click here for the final research plan from the USPSTF for weight management in children and adolescents. For the 2017 recommendations, click here, and then here for more on the ethical issues with implementing them.

Portrait of Actor and Dramatist Grigory Grigorievich Ghe, painting by Ilya Repin / WikiArt

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July 3, 2022