Draft Recommendation Statement

Obesity in Children and Adolescents: Screening

November 01, 2016

Recommendations made by the USPSTF are independent of the U.S. government. They should not be construed as an official position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.

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Importance

Approximately 17% of children and adolescents ages 2 to 19 years in the United States have obesity (defined as an age- and sex-specific body mass index [BMI] in the ≥95th percentile).1-3 Almost 32% of children and adolescents are overweight (defined as an age- and sex-specific BMI in the 85th to 94th percentile) or have obesity.1,2 Although the overall rate of child and adolescent obesity has stabilized over the last decade after increasing steadily for three decades, obesity rates continue to increase in certain populations, such as African American girls and Hispanic boys.3,4 The proportion of children who meet the criteria for severe obesity (class II obesity [BMI ≥35 kg/m2 or ≥120% of the 95th percentile] or class III obesity [BMI ≥40 kg/m2 or 140% of the 95th percentile]) also continues to increase.5

Obesity in children and adolescents is associated with morbidity such as mental health and psychological issues, asthma, obstructive sleep apnea, orthopedic problems, and adverse cardiovascular and metabolic factors (e.g., high blood pressure, abnormal lipid levels, and insulin resistance). Children and adolescents may also endure weight-based victimization (e.g., teasing and bullying). Obesity in childhood and adolescence may continue into adulthood and lead to cardiovascular outcomes or other obesity-related morbidity, such as diabetes.2

Detection

In 2005, the USPSTF found that age- and sex-adjusted BMI (calculated as weight in kilograms divided by the square of height in meters) percentile is the preferred measure for detecting overweight or obesity in children and adolescents because it is feasible for use in primary care, is reliable, and is associated with adult obesity.6-8

Benefits of Early Detection and Treatment or Intervention

The USPSTF found adequate evidence that screening and intensive behavioral interventions for obesity in children and adolescents age 6 years and older can effectively lead to improvements in weight status and certain related cardiometabolic factors after 6 to 12 months. The magnitude of this benefit is moderate.

Pharmacotherapy interventions (i.e., orlistat and metformin) showed small amounts of weight loss. The magnitude of this benefit is of uncertain clinical significance because the evidence regarding the effectiveness of metformin and orlistat is inadequate.

Harms of Early Detection and Treatment or Intervention

The USPSTF found adequate evidence to bound the harms of screening and comprehensive, intensive behavioral interventions for obesity in children and adolescents as small to none, based on the likely minimal harms of using BMI as a screening tool, the absence of reported harms in the evidence on behavioral interventions, and the noninvasive nature of the interventions.

Evidence on the harms associated with metformin is inadequate. Adequate evidence shows that orlistat has moderate harms, including abdominal pain or cramps, flatus with discharge, fecal incontinence, and fatty or oily stools.

USPSTF Assessment

The USPSTF concludes with moderate certainty that the net benefit of screening for obesity in children and adolescents age 6 years and older and offering or referring them to comprehensive, intensive behavioral interventions to promote improvements in weight status and certain cardiometabolic factors is moderate.

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Patient Population Under Consideration

This recommendation applies to children and adolescents ages 6 to 18 years. The USPSTF did not find sufficient evidence on screening in children younger than age 6 years.

Assessment of Risk

Although all children are at risk for obesity and should be screened, there are several risk factors, including parental obesity, poor nutrition, low levels of physical activity, inadequate sleep, sedentary behaviors, and low family income.2

Risk factors associated with obesity in younger children include maternal diabetes, maternal smoking, gestational weight gain, and rapid infant growth. A decrease in physical activity in young children is a risk factor for obesity later in adolescence. Obesity rates continue to increase in some racial/ethnic minority populations. These racial/ethnic differences in obesity prevalence are likely a result of both genetic and nongenetic factors (e.g., socioeconomic status, intake of sugar-sweetened beverages and fast food, and having a television in the bedroom).2 The prevalence of obesity is approximately 21% to 25% among African American and Hispanic children age 6 years and older.1,2 In contrast, the prevalence of obesity ranges from 3.7% among Asian girls ages 6 to 11 years to 20.9% among non-Hispanic white adolescent girls.1,2

Screening Tests

BMI measurement is the recommended screening test for obesity. BMI percentile is plotted on a growth chart, such as those developed by the Centers for Disease Control and Prevention (CDC), which are based on U.S.-specific, population-based norms for children age 2 years and older.9 Obesity is defined as an age- and sex-specific BMI in the 95th percentile or greater.

Screening Interval

The USPSTF found no evidence regarding appropriate screening intervals for obesity in children and adolescents. Height and weight are routinely measured during health maintenance visits, which facilitates BMI calculation.

Treatment and Implementation

Comprehensive, intensive behavioral interventions with a total of 26 contact hours or more over a period of weeks or months resulted in weight loss (Table 1).2,3 Behavioral interventions with a total of 52 contact hours or more demonstrated greater weight loss and some improvements in cardiometabolic measures. These effective, higher-intensity (≥26 contact hours) behavioral interventions consisted of multiple components.2,3 Although these components varied across interventions, they frequently included sessions targeting both the parent and child (separately, together, or both); offered individual, family, and group sessions; provided information about healthy eating, safe exercising, and reading food labels; encouraged the use of stimulus control (e.g., limiting access to tempting foods and limiting screen time), goal setting, self-monitoring, contingent rewards, and problem solving; and included supervised physical activity sessions. Intensive intervention (≥52 contact hours) studies rarely took place within primary care settings but rather in settings to which primary care clinicians could refer patients.2,3

Adherence to interventions can change their effectiveness. In the included trials, 68% to 95% of participants completed all of the sessions.2 Lower adherence in clinical practice could decrease the overall benefit of these interventions.

Metformin has been used for weight loss in children but is not approved by the U.S. Food and Drug Administration (FDA) for this purpose. Metformin has a small effect on weight (BMI reduction of <1 kg/m2) and is of uncertain clinical significance. Although it probably has small adverse effects, evidence regarding long-term outcomes of metformin use is lacking. In addition, participants in the metformin trials had abnormal insulin or glucose metabolism; most had severe obesity. This limits the applicability of the results to a general pediatric population with obesity. Orlistat is approved by the FDA for use in adolescents age 12 years and older. However, it too has a small effect on weight (BMI reduction of <1 kg/m2) and is of uncertain clinical significance. In addition, orlistat is associated with moderate harms. Therefore, the USPSTF encourages clinicians to promote behavioral interventions as the primary effective intervention for weight loss in children and adolescents.

Clinically Important Weight Loss

Researchers use a standardized measure (z-score) of BMI known as zBMI. This measure helps compare results from studies that measure weight differently. A few observational studies have addressed the question of what change in zBMI or excess weight represents a clinically important change. These studies showed that a zBMI reduction of 0.15 to 0.25 is associated with improvements in cardiometabolic measures.2,3 A German expert panel determined that a zBMI reduction of 0.20 is clinically significant and is comparable to a weight loss of approximately 5%.10 A zBMI reduction in the range of 0.20 to 0.25 appears to be a suitable threshold for clinically important change.2

An analysis by Epstein and colleagues of 10-year outcomes from four randomized, controlled trials of family-based behavioral obesity treatment programs suggests an association between weight loss in childhood and decreased risk of obesity in early adulthood. Participants were ages 8 to 12 years at baseline (mean age, 10.4 years), and the average age at followup was 20 years.2,11,12  Almost all participants (about 85%) had obesity at baseline. The comprehensive behavioral interventions involved 30 contact hours or more with the families. Among children with obesity, 52% continued to have obesity as adults.2,11,12 In contrast, naturalistic longitudinal studies with similar followup periods report obesity rates of 64% to 87% in adults who had obesity as children; U.S.-based studies are often at the upper end of the range.8,13-15

Additional Approaches to Prevention

The Community Preventive Services Task Force recommends behavioral interventions to reduce sedentary screen time among children age 13 years and younger.16 It found insufficient evidence to recommend school-based obesity programs to prevent or reduce overweight and obesity among children and adolescents.17 These recommendations are available on the Community Preventive Services Task Force Web site (www.thecommunityguide.org/topic/obesity).

The CDC recommends 26 separate community strategies to prevent obesity, such as promoting breastfeeding, promoting access to affordable healthy food and beverages, promoting healthy food and beverage choices, and fostering physical activity among children.18

Useful Resources

In a separate recommendation, the USPSTF concluded that there is insufficient evidence to assess the balance of benefits and harms of screening for primary hypertension in asymptomatic children and adolescents to prevent subsequent cardiovascular disease in childhood or adulthood (I statement).19 The USPSTF has also concluded that there is insufficient evidence to assess the balance of benefits and harms of screening for lipid disorders in children and adolescents (I statement).20 These recommendations are available on the USPSTF Web site (www.uspreventiveservicestaskforce.org).

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Research Needs and Gaps

The USPSTF identified several areas in need of further research. Trials evaluating the direct benefit and harms of screening for obesity in children and adolescents are needed. One such trial could implement a systematic screening and treatment program in one set of clinics/providers but continue with usual care in another set of clinics/providers. Reproducing existing effective interventions and conducting full trials of small feasibility studies are necessary next steps. Further investigations to determine the specific effective components of behavioral interventions are needed. Long-term followup of participants after completion of treatment is needed to confirm maintenance of weight loss and to assess long-term harms. More studies are needed that address behavioral interventions in diverse populations and younger children (age ≤5 years). Also, more evidence is needed about what constitutes clinically important health benefits and the amount of weight loss associated with those health benefits. The quality of study methods and reporting in recent studies is much better than in the earlier literature; however, the field would benefit further from improved consistency in reporting health outcomes. Individual patient meta-analysis could be beneficial in helping understand the differences between patients who lose weight and those who do not.

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Burden of Disease

Recent prevalence figures from 2011 to 2012 indicate that 17% of children and adolescents ages 2 to 19 years in the United States have obesity.1 Children and adolescents ages 6 to 19 years are more likely to have obesity than children ages 2 to 5 years.1,2 Although overt cardiovascular disease can take many years to develop, obesity is associated with poor cardiovascular and metabolic outcomes during childhood (e.g., high blood pressure, abnormal lipid levels, and insulin resistance). In addition, conditions such as asthma, obstructive sleep apnea, orthopedic problems, early maturation, polycystic ovarian syndrome, and hepatic steatosis are associated with childhood and adolescent obesity. Children may experience low self-esteem, impaired quality of life, and weight-based victimization (e.g., teasing and bullying).2

Obesity can have short-term effects on the health of children and adolescents. In addition, an important concern is that obesity in childhood and adolescence often leads to obesity in adulthood, which leads to poor health outcomes. Large, prospective longitudinal studies show that almost 80% of adolescents with obesity will have obesity as adults (70% when BMI is measured at age ≥30 years).2,13 Approximately 64% of preadolescents with obesity also had obesity as adults. Meta-analyses have shown a strong association between childhood and adult obesity; children with obesity are about 5 times more likely to have obesity as adults than children without obesity.2,13

Scope of Review

The USPSTF examined the evidence on screening for obesity in children and adolescents and the benefits and harms of weight management interventions. Bariatric surgery, which is reserved for patients with morbid obesity, who are easily identified without screening, and obesity prevention interventions for children with normal weight were considered to be outside the scope of this review.

Accuracy of Screening Tests

The USPSTF previously found evidence that BMI is an adequate screening measure for identifying children and adolescents with obesity.6-8

Effectiveness of Early Detection and Interventions

The USPSTF found no direct evidence that addressed the benefits of screening for obesity in children and adolescents to improve intermediate or health outcomes. Estimated time of contact was the only behavioral intervention component associated with effect size (p<0.001).2,3 Evidence was insufficient to examine differences in effect by patient demographic characteristics (e.g., race/ethnicity, sex).2

Behavioral Interventions

The USPSTF reviewed 45 trials (n=7,099) of behavioral interventions for obesity. Of these, 42 trials (n=6,956) used multicomponent interventions targeting lifestyle change (e.g., counseling on diet, increasing physical activity/decreasing sedentary behavior, and addressing behavior change) to limit weight gain or decrease weight. Three smaller trials assessed different behavioral approaches (weight loss maintenance, regulation of cues for overeating, and interpersonal therapy).2

Of the 42 behavioral intervention trials (n=6,956), eight were of good quality and 34 were of fair quality. Half of the trials were conducted in the United States; the rest were conducted in Europe, Israel, or Australia.2 Forty-three percent of trials were conducted in primary care settings and 43% took place in another health care setting. The remaining trials were conducted outside of a health care setting. Trials included children and adolescents ages 2 to 19 years; almost half of the trials were limited to elementary school-aged children (ages 6 to 8 years up to age 12 years).2 Slightly more than half of the participants were girls. Most trials did not report on race/ethnicity or had predominantly white participants. Trials included children with obesity only or both overweight and obesity.2 Average baseline BMI was 18.7 kg/m2 in trials of preschool-aged children, 23.5 kg/m2 in trials of elementary school-aged children, and 32.2 kg/m2 in trials of adolescents. Time of contact in the interventions ranged from 1 to 122 hours (over 4 to 122 sessions); seven studies had 52 contact hours or more, nine studies had 26 to 51 contact hours, 11 studies had 6 to 25 contact hours, and 15 studies had 15 contact hours or less.2 Sessions took place over 2.25 to 24 months. Data on followup beyond 1 year were limited. The trials with minimal contact time (≤5 hours) were often conducted in primary care settings and involved individual sessions. Interventions with more contact time included group sessions, with or without individual sessions; targeted the child, parents, or both; and usually took place in specialty settings. Trials with 52 contact hours or more often included supervised physical activity sessions, as did approximately half of the trials with 26 to 51 contact hours.2

All seven trials with 52 contact hours or more demonstrated benefits of treatment, with a pooled standardized mean difference in change of -1.10 (95% CI, -1.30 to -0.89; k=6; I2=43.4%) among studies with adequate data to pool. Nine trials with 26 to 51 contact hours showed smaller effects, with a pooled standardized mean difference in change of -0.34 (95% CI, -0.52 to -0.16; k=9; I2=24%).2 Among the more intensive trials (≥26 contact hours), intervention groups showed absolute reductions in zBMI (a standardized measure of BMI based on age- and sex-specific norms to facilitate comparison across studies) of 0.20 or greater. Most participants maintained their baseline weight within 5 lbs while growing in height. In comparison, control groups showed small increases or reductions in zBMI of less than 0.10 or weight gain of 5 to 17 lbs (Table 2).2 Interventions were effective in reducing excess weight in children and adolescents after 6 to 12 months. Across all categories of intervention intensity, children in both the intervention and control groups showed a broad range of effects. Some participants had large reductions in weight, some showed no or modest changes, and some continued to gain weight.2 Very limited evidence suggests that briefer interventions may be effective in children who are overweight only. Only three of the 24 trials with less than 26 contact hours showed statistically significant benefits of treatment. Two of the three studies were in children who were overweight but did not have obesity.2 Standardized effect sizes were typically small (absolute zBMI reduction of ≤0.10 in intervention groups). Although the effects in the less intensive trials were seldom statistically significant, intervention groups frequently showed greater average reductions in excess weight than control groups.2

Cardiometabolic outcomes were consistently reported in studies with 52 contact hours or more. Pooled reductions in systolic (pooled mean difference in change between groups, -6.4 mm Hg [95% CI, -8.6 to -4.2]; k=6; I2=51%) and diastolic blood pressure (pooled mean difference in change between groups, -4.0 mm Hg [95% CI, -5.6 to -2.5]; k=6; I2=17%) were statistically significant.2 Pooled results did not demonstrate statistically significant improvements in lipid or fasting plasma glucose levels but some improvements in insulin/glucose measures. Cardiometabolic outcomes were reported less frequently in trials with fewer contact hours, and pooled results were not associated with improvements in blood pressure, lipid levels, or insulin/glucose levels.2

Eleven trials (n=1,523) of behavioral interventions reported on quality of life or functioning, self-esteem, body satisfaction, and depression outcomes. Trial results mostly demonstrated small, statistically nonsignificant increases in quality of life scores.2 Five of these trials reported on self-esteem outcomes and five reported on body satisfaction outcomes; no group differences were found.2 One trial reported no group differences in the percent screening positive for depression. No trials reported on other health outcomes, such as morbidity associated with type 2 diabetes or hypertension, orthopedic pain, sleep apnea, or adult obesity.2

The remaining three small trials that were not multicomponent or that targeted weight loss maintenance did not find benefit.2 The small weight maintenance trial (n=61) found no group differences in body weight, body composition, glucose or insulin levels, or lipid levels. Two small pilot trials (n=82) that targeted overeating used regulation of cues or interpersonal therapy approaches and found no group differences in zBMI or BMI.2

Pharmacotherapy Interventions

Metformin and orlistat are associated with small reductions in excess weight (BMI reduction of <1 kg/m2 or about 5 to 7 lbs) compared with placebo, and have mild to moderate gastrointestinal side effects which, when considered collectively, provide small or no benefit on health outcomes.

Eleven trials (n=1,395) examined the benefits of pharmacotherapy interventions compared with placebo. Ten of these trials were of fair quality and the other trial was of good quality. A little more than half of the trials focused on adolescents only; the rest included younger children. Approximately two thirds of the participants were girls.2 None of the trials were conducted in a primary care setting; rather, trials took place in pediatric obesity, endocrine, or research clinics. Trials were conducted in the United States (64%), United Kingdom, Canada, Australia, Germany, and Switzerland. Among trials that reported race/ethnicity, 25% to 89% of participants were white. Most pharmacotherapy trials only followed participants for 6 months.2 Only one trial assessed the effects of pharmacotherapy after discontinuation.

The average baseline BMI in the pharmacotherapy intervention trials (metformin: 36.0 kg/m2; orlistat: 37.4 kg/m2) was higher than in the behavioral intervention trials. Adherence was reported inconsistently.2 One pharmacotherapy trial included behavioral interventions, while three trials offered group physical activity sessions; none involved primary care clinicians. Metformin dosage ranged from 1 to 2 g per day; orlistat dosage was 360 mg per day in all three trials.2

Metformin. One good-quality and seven fair-quality trials (n=616) showed small effect sizes of weight reduction in intervention groups compared with placebo. Pooled results showed a reduction in zBMI of 0.10 (95% CI, -0.17 to -0.03); k=6; I2=13.1%) and a reduction in BMI of -0.86 kg/m2 (95% CI, -1.44 to -0.29; k=6; I2=0%). All participants had abnormal insulin or glucose metabolism.2 Most participants also met adult criteria for severe obesity. Trials showed no benefit on blood pressure or lipid levels and a small benefit on insulin/glucose levels. No metformin trials reported health outcomes.2 One trial demonstrated that the effect of metformin dissipates after 12 to 24 weeks of discontinuation.2

Orlistat. Three fair-quality trials (n=779) showed small reductions in excess weight in intervention groups compared with placebo. Orlistat was associated with small reductions in BMI ranging from -0.94 (95% CI, -1.58 to -0.30) to -0.50 (95% CI, -7.62 to 6.62) and weight ranging from -3.90 kg (95% CI, -25.54 to 17.74) to -2.61 kg (CI not reported; p<0.001).2 The one trial reporting zBMI showed a between-group difference of -0.06 (95% CI, -0.12 to 0.00). Most studies found no benefits on cardiometabolic outcomes, except for a reduction in diastolic blood pressure in one trial (mean difference in change, -1.81 mm Hg [CI not reported]; p=0.04). One trial reported quality of life measures and found no differences between intervention and placebo groups at 6 months.2

Potential Harms of Screening and Treatment or Interventions

The USPSTF found no direct evidence addressing the harms of screening for obesity in children and adolescents.

Behavioral Interventions

Ten trials (n=1,232) examined the harms of behavioral interventions. Four trials were of good quality and six were of fair quality. Five trials found no adverse or serious adverse events in the intervention group. Five trials found no group differences in disordered eating or body dissatisfaction.2

Pharmacotherapy Interventions

Fourteen trials (n=1,484) were included for adverse effects of pharmacotherapy.

Metformin. Eleven trials (n=705) examined the harms of metformin. Ten trials were of fair quality and the other trial was of good quality. Gastrointestinal side effects (e.g., nausea, vomiting, diarrhea) were common in both the intervention and placebo groups but not serious. Vomiting, for example, was reported by 15% to 42% of participants taking metformin in two trials and by 3% and 21% of control group participants.2 Rates of discontinuation due to adverse effects were 3.8% in the metformin groups and 3.2% in the placebo groups. Trials showed no differences in kidney or liver function. No cases of lactic acidosis were reported.2

Orlistat. Three fair-quality trials (n=779) found that gastrointestinal side effects were more common in the intervention groups than in the placebo groups.2 Gastrointestinal side effects were very common among patients taking orlistat. Fatty or oily stools were reported by 50% to 70% of participants taking orlistat and 0% to 8% of those taking placebo, and uncontrolled passage of stool or oil was reported by 60% of participants taking orlistat and 11% of those taking a placebo.2 Abdominal pain or cramps were reported by 16% to 65% of participants taking orlistat and 11% to 26% of those taking a placebo, flatus with discharge was reported by 20% to 43% of those taking orlistat and 3% to 11% of those taking placebo, and fecal incontinence was reported by 9% to 10% of those taking orlistat and 0% to 1% of those taking placebo.2 One possibly related serious adverse event was reported (cholecystectomy) in a participant who lost 15.8 kg. Discontinuation rates due to adverse effects were twice as common in the intervention group than in the placebo group (3.2% vs. 1.7%, respectively).2 However, prescribing data from the United Kingdom show that discontinuation rates of orlistat in adolescents are about 50% after 1 month.21

Estimate of Magnitude of Net Benefit

The USPSTF concludes with moderate certainty that there is a moderate net benefit of screening for obesity in children and adolescents age 6 years and older. Previously, the USPSTF found adequate evidence that BMI is an acceptable measure for screening for excess weight in children and adolescents. The USPSTF found adequate evidence that comprehensive, intensive behavioral interventions in children and adolescents age 6 years and older who have obesity can result in improvements in weight status for up to 12 months. It found inadequate evidence regarding the effectiveness of less intensive interventions. It found adequate evidence to bound the harms of behavioral interventions as small to none. The USPSTF judged the harms of screening to be minimal.

How Does Evidence Fit With Biological Understanding?

Genetics and various environmental factors play important roles in the development of obesity. Upon developing obesity, an individual’s biochemical feedback mechanisms work to sustain the body’s weight gain.22 Changes in neuronal signaling decreases satiety and perceptions of the amount of food eaten.23 As a result, weight loss can be challenging. Prospective data suggest that cardiovascular risk factors in adults without obesity are similar between those who had obesity as children and those who did not.2,24 This suggests that adverse cardiovascular effects in childhood may be reversible with weight loss. This is of particular importance since obesity in childhood and adolescence may continue into adulthood and lead to poor health outcomes.

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This recommendation updates the 2010 USPSTF recommendation statement on screening for obesity in children age 6 years and older (B recommendation).4

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In 2007, an American Medical Association expert committee recommended that clinicians’ assessments include BMI calculation as well as medical and behavioral risks for obesity.25 The American Academy of Pediatrics endorsed these recommendations and further recommends annually plotting BMI for all patients age 2 years and older.26 In 2011, a National Heart, Lung, and Blood Institute expert panel recommended using BMI to screen for obesity in children and adolescents ages 2 to 21 years who are at high risk for obesity (i.e., history of parental obesity, excessive gain in BMI, and change in physical activity).27

In 2015, the Canadian Task Force on Preventive Health recommended growth monitoring for all children and adolescents age 17 years and younger at all appropriate primary care visits. It recommends that primary care clinicians offer or refer children and adolescents with overweight or obesity to structured behavioral interventions aimed at healthy weight management.28

The American Academy of Family Physicians recommends that clinicians screen for obesity in children age 6 years and older and offer or refer them to comprehensive, intensive behavioral interventions to promote improvements in weight status.29 The National Academies Health and Medicine Division (formerly the Institute of Medicine) recommends that clinicians measure weight and length or height at every well-child visit using World Health Organization (ages 0 to 23 months) or CDC growth charts (ages 24 to 59 months).30 The National Association of Pediatric Nurse Practitioners recommends assessing height and weight parameters, including height-to-weight ratio, in children younger than age 2 years and BMI in children age 2 years and older.31

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  1. Viner RM, Hsia Y, Neubert A, Wong IC. Rise in antiobesity drug prescribing for children and adolescents in the UK: a population-based study. Br J Clin Pharmacol. 2009;68(6):844-51.
  2. Schuster DP. Changes in physiology with increasing fat mass. Semin Pediatr Surg. 2009;18(3):126-35.
  3. Rosenbaum M, Kissileff HR, Mayer LE, Hirsch J, Leibel RL. Energy intake in weight-reduced humans. Brain Res. 2010;1350:95-102.
  4. Juonala M, Magnussen CG, Berenson GS, et al. Childhood adiposity, adult adiposity, and cardiovascular risk factors. N Engl J Med. 2011;365(20):1876-85.
  5. Barlow SE; Expert Committee. Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report. Pediatrics. 2007;120(Suppl 4):S164-92.
  6. Committee on Practice and Ambulatory Medicine and Bright Futures Periodicity Schedule Workgroup. 2016 recommendations for preventive pediatric health care. Pediatrics. 2016;137(1):e20153596.
  7. Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents; National Heart, Lung, and Blood Institute. Expert panel on integrated guidelines for cardiovascular health and risk reduction in children and adolescents: summary report. Pediatrics. 2011;128(Suppl 5):S213-56.
  8. Canadian Task Force on Preventive Health Care. Recommendations for growth monitoring, and prevention and management of overweight and obesity in children and youth in primary care. CMAJ. 2015;187(6):411-21.
  9. American Academy of Family Physicians. Clinical preventive service recommendation: obesity, children and adolescents. 2010. http://www.aafp.org/patient-care/clinical-recommendations/all/obesity.html. Accessed October 19, 2016.
  10. Institute of Medicine. Early Childhood Obesity Prevention Policies. Washington, DC: National Academies Press; 2011.
  11. NAPNAP. NAPNAP position statement on the prevention and identification of overweight and obesity in the pediatric population. J Pediatr Health Care. 2015;29(4):A13-5.
  12. Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of childhood and adult obesity in the United States, 2011-2012. JAMA. 2014;311(8):806-14.
  13. O’Connor EA, Evans CV, Burda BU, Walsh ES, Eder M, Lozano P. Screening for Obesity and Intervention for Weight Management in Children and Adolescents: A Systematic Evidence Review for the U.S. Preventive Services Task Force. Evidence Synthesis No. 150. AHRQ Publication No. 15-05219-EF-1. Rockville, MD: Agency for Healthcare Research and Quality; 2016.
  14. O’Connor EA, Evans CV, Burda BU, Walsh ES, Eder M, Lozano P. Screening and treatment for obesity in children and adolescents: systematic evidence review and evidence report for the U.S. Preventive Services Task Force recommendation statement. JAMA. In press.
  15. Dietz WH, Economos CD. Progress in the control of childhood obesity. Pediatrics. 2015;135(3):e559-61.
  16. Skinner AC, Skelton JA. Prevalence and trends in obesity and severe obesity among children in the United States, 1999-2012. JAMA Pediatr. 2014;168(6):561-6.
  17. U.S. Preventive Services Task Force. Screening for obesity in children and adolescents: U.S. Preventive Services Task Force recommendation statement. Pediatrics. 2010;125(2):361-7.
  18. U.S. Preventive Services Task Force. Screening and interventions for overweight in children and adolescents: recommendation statement. Pediatrics. 2005;116(1):205-9.
  19. Whitlock EP, Williams SB, Gold R, Smith PR, Shipman SA. Screening and interventions for childhood overweight: a summary of evidence for the U.S. Preventive Services Task Force. Pediatrics. 2005;116(1):e125-44.
  20. Kuczmarski RJ, Ogden CL, Guo SS, et al. 2000 CDC Growth Charts for the United States: methods and development. Vital Health Stat 11. 2002;(246):1-190.
  21. Wiegand S, Keller KM, Lob-Corzilius T, et al. Predicting weight loss and maintenance in overweight/obese pediatric patients. Horm Res Paediatr. 2014;82(6):380-7.
  22. Epstein LH, Paluch RA, Roemmich JN, Beecher MD. Family-based obesity treatment, then and now: twenty-five years of pediatric obesity treatment. Health Psychol. 2007;26(4):381-91.
  23. Epstein LH, Valoski A, Wing RR, McCurley J. Ten-year outcomes of behavioral family-based treatment for childhood obesity. Health Psychol. 1994;13(5):373-83.
  24. Simmonds M, Burch J, Llewellyn A, et al. The use of measures of obesity in childhood for predicting obesity and the development of obesity-related diseases in adulthood: a systematic review and meta-analysis. Health Technol Assess. 2015;19(43):1-336.
  25. Thompson DR, Obarzanek E, Franko DL, et al. Childhood overweight and cardiovascular disease risk factors: the National Heart, Lung, and Blood Institute Growth and Health Study. J Pediatr. 2007;150(1):18-25.
  26. Stovitz SD, Hannan PJ, Lytle LA, Demerath EW, Pereira MA, Himes JH. Child height and the risk of young-adult obesity. Am J Prev Med. 2010;38(1):74-7.
  27. Community Preventive Services Task Force. Obesity prevention and control: behavioral interventions that aim to reduce recreational sedentary screen time among children. 2015. https://www.thecommunityguide.org/sites/default/files/assets/Obesity-Behavioral-Screentime.pdf. Accessed October 19, 2016.
  28. Community Preventive Services Task Force. Obesity prevention and control: school-based programs. 2013. https://www.thecommunityguide.org/sites/default/files/assets/Obesity-School-based-Programs.pdf. Accessed October 19, 2016.
  29. Centers for Disease Control and Prevention. Overweight and obesity: prevention strategies and guidelines. 2015. http://www.cdc.gov/obesity/resources/strategies-guidelines.html. Accessed October 19, 2016.
  30. U.S. Preventive Services Task Force. Screening for primary hypertension in children and adolescents: U.S. Preventive Services Task Force recommendation statement. Pediatrics. 2013;132(5):907-14.
  31. U.S. Preventive Services Task Force. Screening for lipid disorders in children and adolescents: U.S. Preventive Services Task Force recommendation statement. JAMA. 2016;316(6):625-33.
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Contact Time Number of Trials (N) Trials With Physical Activity Sessions Intervention Approach and Target
≥52 hours 7 (1,252) 100%
  • Group sessions +/- individual sessions
  • Parent-only + child-only + family sessions
  • Referral/specialty clinic setting
  • Frequently provided sessions on healthy eating, safe exercising, and reading food labels; encouraged the use of stimulus control (e.g., limiting access to tempting foods and screen time), goal setting, self-monitoring, contingent rewards, and problem solving
26–51 hours 9 (838) 56%
6–25 hours 11 (1,085) 33%
  • Group sessions +/- individual sessions
  • Referral/specialty clinic setting
1–5 hours

 

 15 (3,781) 0%
  • Individual sessions
  • Usually targeted parents + child together
  • Frequently conducted in primary care settings
  • Used motivational interviewing

* Behavioral interventions with ≥26 contact hours were found to be effective.

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Intervention Intensity, hours† Mean Change in zBMI Difference in Change in zBMI From Baseline
(95% CI)		 Mean Change in Weight, lbs.‡
IG CG IG CG
≥52 -0.05 to -0.34 0.00 to +0.26 -0.31
(-0.16 to -0.46)		 -7 to +3 +8 to +17
26–51 -0.11 to -0.59 -0.20 to +0.40 -0.17
(-0.30 to -0.04)		 Preschool: +1 to +5
Elementary: -6 to +15
Adolescent: +5		 Preschool: +11 to +12
Elementary: +3 to +20
Adolescent: +7
6–25 +0.05 to -0.24 +0.09 to -0.13 0.01
(-0.06 to 0.08)		 Elementary: +6 to +10
Adolescent: -3 to +7		 Elementary: +6 to +10
Adolescent:  -2 to +18
1–5 0 to -0.20 +0.10 to -0.10 -0.09
(-0.14 to -0.05)		 Preschool: +1 to +4
Elementary: +1 to +12
Adolescent: +4		 Preschool: +1 to +4
Elementary: +2 to +18
Adolescent: +6 to +12

* Data presented in this table are limited to trials that reported zBMI.
†Estimated.
‡Age-specific results were available from trials that limited enrollment to only one of the three age categories (preschool, elementary, or adolescent).  Trials with ≥52 contact hours enrolled participants across the three age categories, so age-specific results were not available.

Abbreviations: CG=control group; CI=confidence interval; IG=intervention group; zBMI=body mass index z-score.

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