In this issue of Pediatrics, Smith et al1 describe the challenges with implementing the US Preventive Services Task Force (USPSTF) recommendation for obesity screening in children and adolescents and offering or referring patients and families to behavioral interventions to promote weight improvement. The authors posit that effective behavioral interventions are not feasible to routinely deliver, and this challenge further exacerbates existing health inequities.
The mission of the USPSTF is to make recommendations about clinical preventive services using a transparent, rigorous, and objective methodology. This approach ensures that clinicians and patients understand the evidence. On the basis of the certainty of the evidence and the magnitude of net benefits (eg, benefits minus harms), the USPSTF issues an A, B, C, or D grade or I statement. For clinicians, A and B grades mean to offer routinely, C means to selectively offer, D means to not routinely offer, and I is insufficient evidence to recommend for or against offering a service. Although the Affordable Care Act links coverage to USPSTF recommendations, the USPSTF does not consider cost or implementation when making recommendations.2,3 Clearly, these two aspects are important, but the USPSTF looks to others to develop the evidence and make recommendations on cost and implementation.
As described by Smith et al,1 implementing the USPSTF recommendation for screening for childhood obesity has unique challenges. In reviewing the treatment evidence, the only consistent intervention characteristic to be effective was intensity, with a minimum of 26 hours of contact over 6 months needed for benefit and 52 hours of contact over 6 months resulting in greater effect.4,5 Interventions reviewed were multicomponent and delivered by a multidisciplinary team. Despite screening for childhood obesity being recommended more than a decade ago,6 there remains limited evidence about the proportion of children with obesity who receive interventions of required intensity. However, only 60% of specialized children’s hospitals offer weight loss programs,7 only 25% of clinicians are aware of effective programs in their community,8 and in the authors’ experience, few if any programs are available for patients at no or minimal cost.
The USPSTF is aware of the challenges with implementing effective weight loss interventions and has called for more evidence on the specific components needed for behavioral interventions to be effective. This knowledge can inform the design of more feasible interventions. Annually, the USPSTF prioritizes evidence gaps and submits a report to Congress. The National Institutes of Health considers these priorities when funding research to close these gaps. Obesity screening and counseling has been cited in several reports.9
Smith et al1 further highlight a patient case to show how the feasibility and implementation issues are exacerbated for disadvantaged populations. Families that cannot afford the cost or time to participate in intensive interventions are unlikely to follow through on referrals. Clinicians instead may provide brief counseling and self-directed educational materials, but in the USPSTF evidence review, these are inadequate to change weight status and improve health outcomes. This amounts to offering interventions that are not supported by evidence.
There are overwhelming data that potential lifesaving benefits of recommended services are not equitably available to Black, Indigenous, and Hispanic people.10 These health inequities manifest as disproportionate risk, incidence, morbidity, or mortality for those who are often socially and economically marginalized and medically underserved. As a result, the USPSTF has sought to address health equity in its recommendations. Evidence reviews start with identifying populations with a higher prevalence or who experience greater morbidity or mortality from the condition and then applying rigorous methods to discern causal factors for inequities, which can include systemic racism and implementation barriers.10,11 For most preventive services, there is limited evidence available to address health inequities.
Call to Action
The article by Smith et al1 should be a national call to action. Obesity is a major driver of poor health. Intensive behavioral interventions can change children’s weight status, fundamentally improving their trajectory for health and well-being. Clinicians need to develop collaborative relationships with local programs. Health systems and communities need to create and sustain accessible programs to help children and families in need. Employers, payers, and policy makers need to honor the intent of the Affordable Care Act and provide first-dollar coverage for programs. Researchers need to generate evidence to understand what intervention components are necessary and how to make more feasible interventions and strategies to promote equity. Public health is needed to create communities and environments that support healthy lifestyles and make healthy weight more accessible for all to obtain. Concerted efforts are required from all in our quest to accomplish better care for our children.
Opinions expressed in these commentaries are those of the authors and not necessarily those of the American Academy of Pediatrics or its Committees.
FUNDING: No external funding.
COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2020-048009.
POTENTIAL CONFLICT OF INTEREST: Although Drs Davidson and Silverstein are members of the US Preventive Services Task Force, the ideas in this article reflect the authors’ perspectives and do not necessarily represent the views and policies of the US Preventive Services Task Force; and Dr Krist has indicated he has no potential conflicts of interest to disclose.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.