Ethics of Implementing US Preventive Services Task Force Recommendations for Childhood Obesity

David is a 10-year-old boy from a small rural town in Louisiana. His pediatrician, Dr K, has noted a past medical history of asthma well-controlled by a low-dose inhaled corticosteroid. He is earning good grades in school and enjoys playing video games with his friends. During the well-child visit, Dr K notes that David’s BMI is >95th percentile, a finding consistent with a diagnosis of obesity. Dr K uses motivational interviewing to discuss David’s weight with him and his father, and David’s father responds, “He’s just a growing boy.” Dr K recommends that David receive intensive behavioral counseling to better manage his obesity. However, she informs David’s father that the closest center providing these services is >75 miles away in the nearest city and requires an extensive time commitment. David’s parents work full-time jobs, so this is an infeasible proposition for them, and David’s father worries that taking time away from schoolwork will affect David’s grades. Because there are no local community or clinic-based obesity management options in their area, Dr K instead offers diet and exercise materials as well as practical suggestions that David and his parents can pursue at home.

This case exemplifies a fundamental challenge related to the implementation of the US Preventive Services Task Force (USPSTF) grade B recommendation for childhood obesity: namely, the disjunction between the recommendation of specific preventive services and the accessibility of those services. In 2017, the USPSTF determined that all primary care providers should “screen for obesity in children and adolescents 6 years and older and offer or refer them to comprehensive, intensive behavioral interventions to promote improvements in weight status.”¹  The USPSTF defines these interventions to require ≥26 contact hours in a comprehensive and intensive program, which most often requires a specialty clinic referral outside of the primary care office. Models of programs that were determined to be successful involved a multidisciplinary team (eg, pediatricians, dietitians, psychologists, social workers, physical therapists) and multiple components including individual, group, and/or family sessions, supervised physical activity, education regarding healthy eating, safe exercise, food label literacy, problem solving, and stimulus control.¹  However, these resource-intensive programs are not universally accessible.² 

Per 2015–2016 data from the Centers for Disease Control and Prevention (CDC), 18.5% of children 2 to 19 years old suffer from obesity,³  and evidence reveals significant disparities in prevalence among vulnerable populations. By income, the prevalence of obesity in children 2 to 19 years old in low-income groups was 18.9% vs 10.9% in high-income groups.⁴  By head of household education level, the prevalence was 18.3% in low-education groups versus 9.6% in high-education groups.⁴  Racial disparities are also pronounced, with non-Hispanic Black groups at 22.0%, Hispanic groups at 25.8%, non-Hispanic white groups at 14.1%, and Asian American groups at 11.0%.³  American Indian children also suffer from a high prevalence of obesity.⁵  Furthermore, the racial disparities found between non-Hispanic Black and white children persist despite adjusting for socioeconomic factors.⁶  Finally, there is a definitive mismatch between the need for and accessibility of comprehensive intensive obesity intervention programs. As described by Block and Oken,²  the accessibility problem of obesity intervention programs is twofold. First, there is the issue of cost. Despite the Affordable Care Act's requirement that grade A or B USPSTF recommendations be covered, absent or inadequate insurance persist as significant financial barriers to many.⁷  Second, obesity intervention programs are simply inaccessible across most of the United States. In a Children’s Hospital Association survey, only 60% of children’s hospitals offered programs with sufficient intensity as advised by the USPSTF.⁸  Obesity treatment programs also tend to concentrate in urban environments, which further limits access.² 

David’s case raises multiple questions: what are the ethical responsibilities of the state to the well-being of its children?^9,10  Is health care a right? What does such a right to health care include, and who would be charged with the duties to ensure and protect those rights?¹¹  This analysis explores the practical and concrete questions related to screening ethics and equity approaches in the implementation of evidence-based recommendations, such as those formulated by the USPSTF. Because it is beyond the USPSTF’s scope and mission to integrate concepts such as cost and population-based implementation considerations into their deliberations,^12,13  it raises ethical questions as to how society and health systems ought to best implement preventive services in a manner that ensures equity and access for diverse populations. In this article, we conduct an ethical analysis to explore the considerations that arise when communities do not have the capabilities to fulfill this recommendation and who should be responsible for ensuring its equitable implementation.

The USPSTF was created in 1984 as an independent panel of experts to provide unbiased, evidence-based recommendations to primary care providers regarding prevention-oriented services they should offer to patients showing no signs or symptoms of disease.¹⁴  The USPSTF is supported by evidence-based practice centers, which meticulously appraise the available evidence for a defined clinical preventive service in a systematic review according to strict inclusion and exclusion criteria.¹²  The USPSTF reviews this evidence, determines the effectiveness of the service, estimates the magnitude of harms and benefits for the service, comes to a consensus regarding its net benefit, and issues a recommendation. It grades the strength of the recommendation according to the strength of evidence and magnitude of benefit as “A” (strongly recommends), “B” (recommends), “C” (recommends selectively offering or providing this service to individual patients on the basis of professional judgment and patient preferences), “D” (recommends against), or “I” (insufficient evidence). However, it does not take cost or population-based implementation logistics of such preventive modalities into account.¹³  For example, although its recommendations for screening and preventive interventions are accessible to many communities in the United States, full consideration of the issue of accessibility remains outside the scope and mission of the USPSTF.¹² 

Key to the USPSTF’s mission of issuing evidence-based prevention recommendations is the dissemination and implementation of that guidance. Clearly communicating and widely disseminating USPSTF recommendations to ensure they are adopted and interpreted correctly is critical to maximizing their benefit.¹⁵  Although the USPSTF uses partners to aid in these efforts (eg, American Academy of Pediatrics, American Medical Association, American Academy of Family Physicians, Department of Defense, among others), these organizations are not obligated to ensure the ethical and equitable implementation of USPSTF recommendations.¹²  Their roles as partners are to support the USPSTF by ensuring its recommendations are disseminated and put into practice by primary care clinicians.¹²  The USPSTF may offer advice regarding the clinical implementation of its recommended preventive services and mention factors which may impact that implementation; however, it does not consistently offer guidance about larger public health considerations relevant to the recommendation’s implementation.¹²  Thus, although the USPSTF is “interested in understanding how the target audience uses recommendations, factors that affect the usability, and how USPSTF recommendation implementation may be improved,” implementation science largely remains beyond its direct scope.¹⁵  It remains unable to directly support recommendation implementation within health systems and primary care practices.¹⁵  By describing the mission, capabilities, and scope of the USPSTF in how it arrives at and promotes its recommendations, we can next examine ethical and conceptual challenges which arise in implementing these recommendations.

Screening methodologies represent one of the most important preventive strategies available in public health and clinical preventive medicine. The traditional criteria by which we assess the appropriateness of a screening tool was proposed by Wilson and Jungner,¹⁶  as detailed in Table 1.

Although the Wilson and Jungner criteria are classically considered the standard reference when appraising a potential screening tool, there are other screening criteria lists that have been developed over the years.¹⁷  Yet the core values of this set remain applicable across most criteria lists. One of these values states there ought to be an accepted treatment of the disease being screened.¹⁸  However, if there is an accepted intervention with minimal or no access to that intervention, then there is a real concern about the consequences of screening. This further raises questions concerning another core value of a good screening tool: there should be facilities or sites for treatment available. The lack of accessibility to comprehensive, intensive behavioral interventions for childhood obesity represents a serious concern for many communities. Should clinicians advise preventive interventions to their patients based upon a USPSTF recommendation if there is limited or no accessibility for the practice despite its proven effectiveness and positive risk-benefit calculus?

A comparable case to the USPSTF’s recommendation regarding childhood obesity is their grade B recommendation concerning screening for depression in children and adolescents.¹⁹  In 2016, the USPSTF updated the recommendation regarding the screening of adolescents aged 12 to 18 years for major depressive disorder to say that “screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up.”¹⁹  This was a significant shift from its previous 2009 recommendation which stated that screening should only be performed if such adequate systems were accessible.²⁰  Part of the reasoning behind the change was the acknowledgment that regardless of optimal services being accessible, there remains inherent value and merit to diagnosing, offering counsel, and providing interventions in the primary care setting.¹⁹  The other driving factor for this change was the addition of more evidence supportive of the benefits of depression management in adolescents in the primary care setting.¹⁹ 

A similar case could be made for the screening of childhood obesity. Regardless of the services available, notifying children and their parents that the child has a diagnosis of obesity (a condition with serious ramifications) and that they ought to pursue committed and sustained behavioral interventions might be valuable. However, although it is certainly of value to inform patients and their parents of the condition and potential actions they can take to address obesity, there is little evidence to show that simply conveying that information will result in the behavioral changes necessary for effective treatment. As the USPSTF determined through its extensive evidence review, comprehensive and intensive behavioral interventions in established programs are one of the few evidence-based, successful modalities we have available for addressing childhood obesity. Just as the change in adolescent depression screening implores us implicitly to ensure appropriate access to interventions in resource-limited communities, so does it for obesity interventions as well.

The USPSTF recommendation does not just say that primary care providers ought to screen for obesity, but also that, when screened positive, those children should be offered or referred to a comprehensive, intensive behavioral intervention program. For many other screening tools for other conditions, there is an automatic and compulsory reflex from the clinician to refer patients to the appropriate next intervention step, even when the cost of that intervention may be high or access may be limited. For example, if a patient screens positive on fecal occult blood test or Papanicolaou test, they are immediately referred to the next stage of testing or interventions (eg, colonoscopy, biopsy, colposcopy, etc). Yet that same level of urgency and referral reflex has not been the case for childhood obesity. There are serious and costly health, quality of life, and social consequences if obesity is not addressed effectively and early.^20–22 

Despite the known negative consequences of obesity, normalized views of it have had serious detrimental implications for millions of Americans. Public opinion polls show that Americans generally see obesity as a serious public health problem (52% thought it was a major problem in their community), but not for themselves or their children (only 17% reported being overweight as a major problem in their family, and only 12% of parents of children <18 said any of their children were overweight).²³  Furthermore, physicians with obesity are less likely to refer patients with obesity for obesity interventions or document the patient’s obesity in their charting compared with physicians without obesity.^24,25  Studies such as these underscore the deleterious effects the normalization of obesity has had on parents’ perceptions of themselves and their children and the assessments of patients by clinicians. If Americans cannot identify obesity as an issue at the personal or individual level, they will not afford it the urgency warranted to sufficiently address it, especially when family readiness and willingness to engage in the recommended intensive program is an important factor in the screening-to-treatment success pathway. As such, implementation of the USPSTF recommendation for screening children and adolescents can provide the impetus for the clinician–parent/patient conversation identifying obesity as an issue requiring mediation, which is an essential factor in driving demand for adequate treatment interventions to address obesity.

These issues facing childhood obesity interventions illustrate the need to define and extend the values by which we implement both clinical- and community-based prevention and treatment recommendations. Equitable distribution and accessibility of these interventions are essential values in addressing childhood obesity in an ethical manner. If certain demographic groups are found to be systematically and consistently without access to these interventions, then there is a heightened ethical imperative to provide access. The circumstances become even more pronounced when considering vulnerable populations such as children and adolescents.

According to the CDC, health equity is defined as “when everyone has the opportunity to be as healthy as possible.”²⁶  The CDC also notes that, “Reducing and eliminating health disparities is fundamental to reaching health equity and building a healthier nation.”²⁶  There is a key distinction here between health equality and health equity. Equality exists when everyone is offered the same exact service. However, there are instances where different solutions may be necessary to resolve issues of disparity and simple equality is not enough. For example, the referral to intensive behavioral counseling to all children with obesity may occur in all clinics, whereas the accessibility of the services differs. Thus, a physician who makes the recommendation or referral may be providing sufficient care when such resources are accessible, but the equality in referral may not be sufficient in an area where such services are largely inaccessible. In other words, for a child like David, a referral to intensive behavioral services that are inaccessible may not be actionable. However, for a different child in a high-resource area where the referral can be used, the referral can be actionable and may be incredibly important.

So, what happens when intervention services are systematically inaccessible for specific population subgroups (eg, via race and ethnicity, socioeconomic status, etc)? If justice and equity are considered ethical imperatives, then although there may not be an explicit right to such services or a state duty to provide them, efforts ought to be made to fill in these gaps and meet standards of care. This offers an additional ethical impetus to work to address these areas to prevent further exacerbation of existing disparities.

If we agree that the concept of prevention is valuable; that USPSTF recommendations are strong, well-researched, and effective and ought to continue without recognition of cost; and that health equity is important, then efforts ought to be put forth to ensure that all children have access to these intervention modalities, and particularly for children in higher prevalence and higher risk groups. So how might these gaps be filled? There are many ways to address the gaps, and we briefly discuss 5 such methods.

First, one could consider better incentivizing the provision of intensive behavioral counseling for obesity in children. Financial incentives have been shown to affect changes in behavior, particularly in medical systems.²⁷  It is possible that this approach may lead to the creation of additional facilities and intensive services. However, if not, this may widen the equity gap and may carry its own set of ethical concerns.²⁸  When reimbursement for quality performance metrics are based on evidence-based recommendations, resource-poor areas may face a more difficult time reaching those metrics and may not be able to obtain any financial incentives associated with doing so.

A second option is to expand clinical services so that physicians in low-resource areas are trained to provide the intensive behavioral counseling for obesity in children. Yet this option is not without challenges. Adding another responsibility or burden to primary care doctors is unlikely to be the best solution, particularly in areas where primary care doctors are scarce and where the primary care shortage may be growing. Without addressing the underlying primary care shortage and clustering in urban and higher income areas, physicians in low-resource practices may consider intensive behavioral counseling as one more task on the long list of services that they may already have difficulty providing. They may not have nurses, physician assistants, dieticians, nutritionists, or other providers who can help meet this need.

A third option involves expanding and strengthening the collaborative network of stakeholders, including public health, clinicians, social justice organizations, and communities. Perhaps these groups who are most concerned with health disparities ought to evaluate the USPSTF recommendations for equity, cost, and access concerns on their release. For example, health departments throughout the country have worked collaboratively with stakeholders to help fill gaps in health services through activities like coordinating mammogram screening for breast cancer or providing sexually transmitted infection testing to control burden and transmission. However, again, the greater burden tends to fall on lower-resource areas with larger needs, and resources may not be aligned to address this challenge.

Fourth, it is important to recognize that recommendations and interventions remain available at all levels of care for childhood obesity, including those at the community level. Like the USPSTF, the Community Preventive Services Task Force was created as an independent, nonfederal group to develop guidance using scientific evidence regarding community-based preventive interventions and services, and offers recommendations regarding topics such as obesity. For example, the Community Preventive Services Task Force found favorable outcomes with self-monitored digital health interventions in overweight teenagers, with the possibility of decreasing barriers to access and meeting adolescents at their level by incorporating technology into interventions.²⁷  Other interventions with less evidence to support them, such as motivational interviewing and intervening on co-occurring conditions like depression, can also be easily implemented in the primary care setting and could potentially be paired with other evidence-proven community programs targeting obesity and related conditions, such as school-based healthy eating or physical activity interventions.^29,30  Some clinics or communities may not have the resources to deliver comprehensive, intensive, evidence-based interventions. However, they may be able to provide the diagnosis in clinic, bring attention to the issue, and subsequently engage in alternative options that are less resource intensive, recognizing possible gaps in the evidence for their effectiveness.

Finally, another key consideration in ensuring the equitable implementation of USPSTF recommendations across populations is addressing evidence gaps for vulnerable and disadvantaged populations. The USPSTF seeks to implement the best available evidence for clinical preventive services across all populations; however, the data regarding diverse and vulnerable populations are often lacking, and services are not equitably available to Black, Indigenous, and Hispanic/Latinx people.³¹  The evidence gap and inequity in services which perpetuate structural racism are concerns that the USPSTF has called to be addressed broadly^31–33  and specifically for its childhood obesity recommendation.³²  When there is evidence relevant to specific populations (eg, variations in the epidemiology of the disease or the effectiveness of the preventive service), the USPSTF may issue separate grades for distinct populations (eg, by sex, age, race and ethnicity, etc).³²  Yet oftentimes, there is a dearth of evidence on subgroups, which limits the USPSTF’s ability to offer population-specific guidance. This is a concern the USPSTF raises in stating³⁴ :

Thus, if the USPSTF is to offer nuanced recommendations for clinical preventive services, it needs the evidence to be able to do so. Within their obesity recommendation, the USPSTF calls out this gap in evidence and identifies a need to conduct research that reproduces the existing effective interventions and identifies the specific effective components of the behavioral interventions, and further states that “more studies are needed that address behavioral interventions in diverse populations and younger children (age ≤5 years).”¹  As such, an upstream method to implement childhood obesity interventions ethically and equitably is to first perform the research that studies the effectiveness of screening and interventions in diverse and vulnerable populations. A key component to this might include an emphasis on comparative effectiveness studies that rank clinical and community preventive services for childhood obesity with a special focus on vulnerable and resource-constrained populations.

Although the research needs and gaps raised by the USPSTF are used by the National Institutes of Health to help direct funding streams for future research, further innovative solutions, integrated partnerships, and long-term funding commitments will likely be required to confront this complex issue.³⁵  When addressing the equitable implementation of preventive interventions, it is important to remain cognizant that additional burdens and responsibilities are not being placed solely on physicians, practices, and public health agencies in low-resource areas that may already be faced with many additional challenges, especially if additional resources are not allocated to address these specific areas. Thus, there may be a larger ethical need for funding to build and maintain the capacity to address childhood obesity in low-resource areas as part of a national strategy to eliminate disparities. Ultimately, it is essential to recognize that effectively addressing childhood obesity at a population level and achieving health equity³⁶  must also focus on preventing obesity through improving social determinants of health and other systemic causes of obesity.

Children deserve the right to an open future, one in which they, after reaching adulthood, have the ability to decide how they would like to shape the long arc of their lives.^37,38  By not having screening and preventive intervention modalities for childhood obesity accessible equitably across populations, disparities are created and exacerbated between groups. Obesity can incur a terrible toll on those in whom it afflicts, ranging from impaired mental health to restricted mobility to organ failure and more.³⁹  These comorbid and associated conditions can then limit a person’s ability to fully pursue their goals unencumbered. If the American Dream is one in which individuals of any socioeconomic stratum or geographic background have the potential to successfully pursue their goals, then we are betraying this dream by leaving the inequities of childhood obesity unaddressed. This point becomes particularly pronounced after the realization that we have USPSTF-recommended (ie, evidence-based and effective) screening and preventive interventions for this disease, but that these services remain inaccessible or limited for many of the populations who need it most.

After preventive actions have been verified as effective and worthwhile via reliable organizations such as the USPSTF, it is essential that public health officials and stakeholders ensure that such recommendations are being implemented universally and particularly where they are needed most so as to not exacerbate existing disparities. There is a similar upstream ethical impetus for conducting more research that includes vulnerable and diverse populations to better support the USPSTF’s efforts in tailoring recommendations for these groups and promoting representation in research. Creative solutions, such as collaboration with community programs, video links, telemedicine, and so on, may be necessary to ensure that limited resource areas can establish and bolster childhood obesity interventions. Governmental and political support will likely be necessary to ensure such solutions are realizable. While these gaps are being addressed, screening for childhood obesity should continue, and clinicians should place a greater emphasis on screening, documenting, and offering interventions and counseling as available to all their pediatric patients regarding obesity.

Childhood obesity represents a serious threat to the health of our country. We in the medical professions and as a society must more seriously consider obesity’s place as a highly deleterious health condition that warrants vigilant recognition and prompt intervention. By failing to do so, we are placing our children’s health in jeopardy and potentially restricting their rights to open futures.

The authors are grateful to Drs Brook Belay, Heidi Blanck, Jennifer Chevinsky, and Alyson Goodman from the Centers for Disease Control and Prevention’s Obesity Prevention and Control Branch for their valuable public health input.

USPSTF

US Preventive Services Task Force

CDC

Centers for Disease Control and Prevention