Although practice guidelines suggest that primary care providers working with children and adolescents incorporate BMI surveillance and counseling into routine practice, the evidence base for this practice is unclear.
To determine the effect of brief, primary care interventions for pediatric weight management on BMI.
Medline, CENTRAL, Embase, PsycInfo, and CINAHL were searched for relevant publications from January 1976 to March 2016 and cross-referenced with published studies.
Eligible studies were randomized controlled trials and quasi-experimental studies that compared the effect of office-based primary care weight management interventions to any control intervention on percent BMI or BMI z scores in children aged 2 to 18 years.
Two reviewers independently screened sources, extracted data on participant, intervention, and study characteristics, z-BMI/percent BMI, harms, and study quality using the Cochrane and Newcastle-Ottawa risk of bias tools.
A random effects model was used to pool the effect size across eligible 10 randomized controlled trials and 2 quasi-experimental studies. Compared with usual care or control treatment, brief interventions feasible for primary care were associated with a significant but small reduction in BMI z score (–0.04, [95% confidence interval, –0.08 to –0.01]; P = .02) and a nonsignificant effect on body satisfaction (standardized mean difference 0.00, [95% confidence interval, –0.21 to 0.22]; P = .98).
Studies had methodological limitations, follow-up was brief, and adverse effects were not commonly measured.
BMI surveillance and counseling has a marginal effect on BMI, highlighting the need for revised practice guidelines and the development of novel approaches for providers to address this problem.
Comments
RE: Counseling on Obesity: Silence Is Not Acceptable
In their article, “Brief Primary Care Obesity Interventions: A Meta-Analysis,” Sim et al. find that primary care interventions are clinically ineffective at reducing BMI over the short intervals studied. Although the selected studies were limited by both the type of intervention as well as the length, if any, of follow up, the authors generalize that primary care interventions may reflect a poor utilization of time and effort for general pediatricians. Clinically meaningful interventions may not be present in short term studies, but the idea that as pediatricians we should opt not to intervene or counsel on a disease that effects nearly 1/3 of our patient population seems counter to our role as physicians. Primary care pediatricians have the advantage of longitudinal relationships with patients and have the opportunity to intervene at multiple stages of development, including early childhood, preadolescence, and adolescence. As with many other counseling efforts in primary care, e.g., injury prevention, smoking cessation, and media use, the pediatrician never knows when the message will contribute to behavior change. Clearly, well-designed studies assessing the effectiveness of primary care interventions on obesity are needed, but until such studies have been performed, and despite the absence of optimal interventions, pediatricians should reject the idea that silence is an acceptable response to an obesity epidemic that continues to plague the health of our patients. Failure to try ensures failure to impact obesity.
RE: Giving up on treatment of children with obesity?
The conclusions of the review by Sim, “Brief Primary Care Obesity Interventions: A Meta-analysis” are really hard to accept, as commented by Armstrong and Skinner in “Defining "Success" in Childhood Obesity Interventions in Primary Care”. Although the results of BMIzscore reduction are objectively poor, we must not forget that there is no real control group. The comparison in randomized trials is done with children followed and put into care by their pediatricians, in which traditional care works at least in the short term, or children and families warned of the problem and its importance from their pediatrician when consent to the study was requested. Those who have not been warned, nor have started traditional care or counseling, obviously do not go well, if the prevalence of obesity increases with age, from birth to childhood, from adulthood to the elderly. It means that those who are not doing anything are gaining weight.
The search for a statistical difference is not adequate to study the evolution of BMI Zscore in obesity, as BMIzscore alone does not summarize the suffering and the consequences related to this disease. It not only does not allow evaluation of success, but threatens to kill the very few pediatricians and parents who are still working on it.
The invitation to donate funds to other diseases and change the guidelines in primary care to start new, more challenging and expensive studies seems an insult to the ability to read the historical moment in which we live.