High Body Mass Index in Children and Adolescents: Interventions

The U.S. Preventive Services Task Force (USPSTF) makes recommendations about the effectiveness of specific preventive care services for patients without obvious related signs or symptoms to improve the health of people nationwide. 

It bases its recommendations on the evidence of both the benefits and harms of the service and an assessment of the balance. The USPSTF does not consider the costs of providing a service in this assessment. 

The USPSTF recognizes that clinical decisions involve more considerations than evidence alone. Clinicians should understand the evidence but individualize decision making to the specific patient or situation. Similarly, the USPSTF notes that policy and coverage decisions involve considerations in addition to the evidence of clinical benefits and harms. 

The USPSTF is committed to mitigating the health inequities that prevent many people from fully benefiting from preventive services. Systemic or structural racism results in policies and practices, including health care delivery, that can lead to inequities in health. The USPSTF recognizes that race, ethnicity, and gender are all social rather than biological constructs. However, they are also often important predictors of health risk. The USPSTF is committed to helping reverse the negative impacts of systemic and structural racism, gender-based discrimination, bias, and other sources of health inequities, and their effects on health, throughout its work.

Approximately 19.7% of children and adolescents ages 2 to 19 years in the United States have a body mass index (BMI) at or above the 95th percentile for age and sex, based on Centers for Disease Control and Prevention (CDC) growth charts from 2000.^1,2 BMI percentile is plotted on growth charts, such as those developed by the CDC, which are based on U.S.-specific, population-based norms for children age 2 years or older.^1,3 The prevalence of high BMI increases with age and is higher among Hispanic/Latino, Native American/Alaska Native, and non-Hispanic Black children and adolescents and children from lower-income families.^1,2

The USPSTF concludes with moderate certainty that offering or referring children and adolescents age 6 years or older with a high BMI to comprehensive, intensive behavioral interventions has a moderate net benefit.

See Table 1 for more information on the USPSTF recommendation rationale and assessment. For more details on the methods the USPSTF uses to determine the net benefit, see the USPSTF Procedure Manual.⁴

Patient Population Under Consideration

This recommendation applies to children and adolescents age 6 years or older.

Definitions

Childhood and adolescent weight status is usually obtained by calculating BMI (weight in kilograms divided by the square of height in meters). Traditionally, children and adolescents’ weight are categorized as having “overweight” when their BMI is between the 85th and 95th percentile, and as having “obesity” when their BMI is at or above the 95th percentile on these charts. In this recommendation, the USPSTF will use the general term “high BMI” when referring to youth considered to be above “normal” body weight status (≥95th percentile for age and sex) according to CDC standards. Specific BMI cut-offs (“≥95th percentile for age and sex” rather than “obese” and “85th to 95th percentile for age and sex” rather than “overweight”) will also be used when feasible. 

Behavioral Counseling Interventions and Implementation Considerations

Comprehensive, intensive behavioral interventions with at least 26 contact hours or more that include supervised physical activity sessions for up to 1 year result in weight loss in children and adolescents.¹ Effective, high-intensity (≥26 contact hours) behavioral interventions result in greater weight loss than less intense interventions, and results in some improvements in cardiometabolic risk factors.¹ These behavioral interventions consist of multiple components. Although components vary across interventions, many of the studied interventions include sessions targeting both the parent and child (separately, together, or both); offer group sessions in addition to individual or single-family sessions; provide information about healthy eating, safe exercising, and reading food labels; and incorporate behavior change techniques such as problem solving, monitoring diet and activity behaviors, and goal setting.¹ These types of interventions are often delivered by multidisciplinary teams, including pediatricians, exercise physiologists or physical therapists, dieticians or diet assistants, psychologists or social workers, or other behavioral specialists.¹ The USPSTF recognizes the challenges that the families of children and adolescents encounter in accessing effective, intensive behavioral interventions for high BMI. Identifying high BMI and how to address it are important steps in helping children and adolescents and their families obtain the support they need.

Pharmacotherapy is associated with moderate harms due to gastrointestinal symptoms (e.g., fecal incontinence, flatus, and gall stones), and there is no evidence on the harms of long-term medication use.¹ Therefore, the USPSTF encourages clinicians to promote behavioral interventions as the primary effective intervention for weight loss in children and adolescents. 

Additional Tools and Resources

The Community Preventive Services Task Force recommends several youth interventions promoting physical activity and healthy eating, access to affordable healthy food and beverages, healthy food and beverage choices, and fostering physical activity among children, reducing sedentary screen time, and using digital health interventions for weight management (https://www.thecommunityguide.org/pages/task-force-findings-obesity.html).

The U.S. Department of Health and Human Services published the “Physical Activity Guidelines for Americans,” which provide recommendations for how physical activity can help promote health and reduce the risk of chronic disease for Americans age 3 years or older (https://health.gov/our-work/nutrition-physical-activity/physical-activity-guidelines).

Other Related USPSTF Recommendations

The USPSTF has issued recommendations on screening for high blood pressure in children and adolescents,⁵ screening for lipid disorders in children and adolescents,⁶ and screening for prediabetes and type 2 diabetes in children and adolescents.⁷ Current versions of these and other related USPSTF recommendations are available at https://www.uspreventiveservicestaskforce.org.

When final, this recommendation will update the 2017 USPSTF recommendation statement on screening for obesity in children and adolescents age 6 years or older (B recommendation).⁸

Scope of Review

The USPSTF commissioned a systematic evidence review to update its 2017 recommendation on screening for obesity in children and adolescents.⁸ Because assessing BMI is now part of routine clinical practice, it was not a focus of this review. The USPSTF reviewed evidence on interventions (behavioral counseling and pharmacotherapy) for weight loss or weight management that can be provided in or referred from a primary care setting. Surgical weight loss interventions are outside the scope of the primary care setting.

Effectiveness of Behavioral Counseling and Pharmacotherapy Interventions

Fifty randomized, controlled trials (RCTs) (N=8,798) examined behavioral interventions. Twenty-eight trials were conducted in the United States; the remaining 22 trials were conducted in Europe, Canada, Australia, New Zealand, Israel, and Turkey. Twenty-seven trials were conducted in primary care settings, and the remaining trials were conducted in other healthcare settings (e.g., various specialty outpatient clinics or research facilities).¹ Most trials (41/50) included study participants who had a BMI at or above the 85th percentile or at or above the 95th percentile for their age or sex according to CDC growth charts, country-specific norms, or International Obesity Task Force norms. The mean BMI percentile was 93 (range, 84.9 to 99.2).¹ Trials included children and adolescents ages 2 to 19 years. Eighteen trials were limited to elementary school–aged children (ages 6 to 8 years, up to age 12 years); 13 trials included preschool-aged or elementary school–aged children to adolescents; 12 trials evaluated adolescents only; and seven trials targeted preschool- to kindergarten-aged children.¹

Most trials did not report on race or ethnicity or included predominantly white study participants. Trials conducted in the United States had a more diverse study population; trials were mostly composed of White (52.4%), Black (20.5%), and Hispanic/Latino (25%) study participants.¹ There was limited inclusion of Native American/Alaska Native or Asian participants. Most trials reported patient participation in interventions. In the included trials, 31% to 93% of participants completed all the sessions. The average percentage of sessions completed generally ranged from 60% to 80%.¹

Trials rarely reported health outcomes (e.g., depression or social adjustment). However, pooled analyses demonstrated a statistically significant increase in global quality of life after 6 to 12 months (mean difference in change, 1.9 [95% CI, 0.2 to 3.5]; 11 RCTs [n=1,922]). Among studies with more contact hours (≥26 contact hours), the mean difference in change in quality of life measures was 3.8 points (95% CI, 3.6 to 4.1).¹ No studies reported longer-term benefits on health outcomes.

Behavioral interventions were associated with reductions in BMI and other weight-related outcomes after 6 to 12 months (mean difference in change between groups, -0.7 kg/m² [95% CI, -1.0 to -0.3 kg/m²]; 28 RCTs [n=4,494]; I²=86.8%). Larger effects (1.4 kg/m²) were seen in interventions with more contact hours and physical activity sessions. Other weight and adiposity outcomes showed similar patterns.¹

Cardiometabolic risk factors (e.g., lipid levels, blood pressure, and fasting plasma glucose level) were reported by 16 trials (n=1,700).¹ Pooled analyses of trials providing 26 or more contact hours and physical activity sessions showed improvements in blood pressure (e.g., mean difference in systolic blood pressure, -3.6 mm Hg [95% CI, -5.7 to -1.5 mm Hg]; 8 RCTs [n=773]; I²=47.3%; mean difference in diastolic blood pressure, -3.0 mm Hg [95% CI, -5.7 to -1.5 mm Hg]; 8 RCTs [n=774]; I²=49.3%) and fasting plasma glucose (mean difference, -1.9 mg/dL [95% CI, -2.7 to -1.2 mg/dL]; 4 RCTs [n=367]; I²=0%) after 6 to 12 months.¹ Pooled results of all 16 studies (including those with <26 contact hours) were not associated with improvements in systolic blood pressure.

The USPSTF found no evidence to determine the individual benefits of specific intervention components. Evidence on effective interventions in children younger than age 6 years is limited.¹

Eight trials assessed pharmacotherapy interventions: liraglutide (3 RCTs [n=296]), semaglutide (1 RCT [n=201]), orlistat (2 RCTs [n=579]), and phentermine and topiramate (2 RCTs [n=269]). Five trials included behavioral counseling components along with the medication or placebo. Seven of the eight trials were either conducted entirely in the United States or had study sites in the United States; the remaining trial was conducted in Germany.¹ The majority of study participants were age 12 years or older or 14 years or older; one study included children ages 7 to 11 years.¹

Only one medication, semaglutide, was associated with a greater improvement in weight-related quality of life (mean difference, 5.3 [95% CI, 0.2 to 8.3]). Three other pharmacotherapy trials found no between-group differences in change in quality of life or depression incidence compared with placebo after 6 to 13 months.¹

Pharmacotherapy was associated with larger mean BMI reductions compared with placebo in most trials. Liraglutide was associated with 1.6 kg/m² greater reduction in BMI than placebo (mean difference, -1.6 kg/m² [95% CI, -2.5 to -0.7 kg/m²] after 13 months), semaglutide with a 6.0 kg/m² greater reduction in BMI, (mean difference, -6.0 kg/m² [95% CI, -7.3 to -4.6 kg/m²] after 16 months), orlistat with a 0.9 kg/m² greater reduction (mean difference, -0.9 kg/m² [95% CI not reported]; p=0.001; after 12 months), and phentermine/topiramate with 3.7 to 5.4 kg/m² greater reductions (15/92 mg dose mean difference, -5.4 kg/m² [95% CI, -6.4 to -4.3 kg/m²]; 7.4/46 mg dose mean difference, -3.7 kg/m² [95% CI, -5.0 to -2.5 kg/m²] after 13 months).¹ Group differences were not maintained in the liraglutide study after 6 months without treatment and longer-term maintenance after medication withdrawal was not reported for any of the other medications. All medications showed increases in the likelihood of losing both 5% and 10% of baseline weight or BMI.¹

Cardiometabolic outcomes were reported for orlistat (2 RCTs) and one study each of phentermine/topiramate, liraglutide, and semaglutide. The only medication that showed a clear reduction in blood pressure was phentermine/topiramate, and only at the higher dose level (mean difference, -4.0 [95% CI, -7.7 to -0.5]).¹ Semaglutide improved low-density lipoprotein cholesterol levels (mean difference in percent change, -7.1 [95% CI, -11.9 to -1.8]), and phentermine/topiramate improved high-density lipoprotein cholesterol levels (e.g., mean difference in percent change, 8.8 [95% CI, 2.2 to 15.4] for 15/92 mg/day dose); other medications did not demonstrate statistically significant improvements. None of the pharmacotherapy trials found improvements in glucose-related parameters.¹

Potential Harms of Behavioral Counseling and Pharmacotherapy Interventions

Eighteen trials (n=2,539) examined the harms of behavioral interventions. Outcomes were reported 6 to 12 months after baseline assessments. None of the trials found an increased risk of any adverse event or serious adverse events, or decreases in self-esteem, body satisfaction, or disordered eating.¹

Eight trials (n=1,345) examined the adverse effects of pharmacotherapy. Gastrointestinal side effects (e.g., gallstones, flatus with discharge, and fecal incontinence) were common among patients taking liraglutide, semaglutide, and orlistat. Musculoskeletal and psychiatric side effects were most reported with phentermine/topiramate (at doses of 15/92 mg/day). Serious adverse effects were rare in all the pharmacotherapy trials. No evidence was available on adverse effects beyond 1 month after medication discontinuation, and no longer than 17 months for any medication.¹

See Table 2 for research needs and gaps related to interventions for high BMI in children and adolescents.

The American Academy of Pediatrics recommends plotting BMI on a growth chart at all pediatric visits for all patients age 2 years or older. It also recommends comprehensive treatment of high BMI with improved nutrition, physical activity, behavioral therapy, and pharmacotherapy for children younger than age 13 years, and consideration of bariatric surgery for adolescents.^9,10

The Canadian Task Force on Preventive Health recommends growth monitoring for all children and adolescents age 17 years or younger at primary care visits. It also recommends that primary care clinicians offer or refer children and adolescents with high BMI to structured behavioral interventions aimed at healthy weight management.¹¹

The American Psychological Association recommends family-based multicomponent behavioral interventions with a minimum of 26 contact hours, initiated at an early age for children and adolescents with overweight or obesity.¹²

The American College of Obstetricians and Gynecologists recommends screening for adolescent overweight and obesity, and that adolescents with overweight or obesity be screened for depression, bullying, and peer victimization and appropriately referred. It also recommends that providers initiate behavioral counseling or other multidisciplinary management as necessary. It does not recommend metformin for adolescent weight loss alone and recommends that bariatric surgery should only be considered after careful candidate selection by a multidisciplinary team.¹³ Additionally, it recommends that clinicians caution against the use of weight loss supplements.

The Society for Adolescent Health and Medicine calculating BMI percentile for all adolescents, reinforcing healthy behaviors, and counseling regarding body image, inappropriate dieting, and weight stigmatization, when indicated. For patients with a high BMI, it also recommends behavioral counseling or, if needed, referral to more intensive treatment options such as weight loss surgery. ¹⁴

The National Association of Pediatric Nurse Practitioners recommends measuring BMI in children age 2 years or older and assessing family eating patterns, physical activity, sedentary time, and daily screen time in all children. It further recommends that weight loss programs be multicomponent and accessible within clinical, schools, or community settings.^15,16

1. O’Connor E, Evans C, Henninger M, Redmond N, Senger C, Thomas R. Interventions for High Body Mass Index in Children and Adolescents: An Evidence Update for the U.S. Preventive Services Task Force. Evidence Synthesis No. 237. AHRQ Publication No. 23-05310-EF-1. Rockville, MD: Agency for Healthcare Research and Quality; 2023.
2. Stierman B, Afflux J, Carroll MD, et al. National Health and Nutrition Examination Survey 2017–March 2020 Prepandemic Data Files—Development of Files and Prevalence Estimates for Selected Health Outcomes. Hyattsville, MD: National Center for Health Statistics; 2021.
3. Centers for Disease Control and Prevention. Defining Childhood BMI Categories. Accessed November 28, 2023. https://www.cdc.gov/obesity/childhood/defining.html
4. U.S. Preventive Services Task Force. Procedure Manual. Accessed December 1, 2023. https://uspreventiveservicestaskforce.org/uspstf/about-uspstf/methods-and-processes/procedure-manual
5. US Preventive Services Task Force. Screening for high blood pressure in children and adolescents: US Preventive Services Task Force recommendation statement. JAMA. 2020;324(18):1878-1883.
6. US Preventive Services Task Force. Screening for lipid disorders in children and adolescents: US Preventive Services Task Force recommendation statement. JAMA. 2023;330(3):253-260.
7. US Preventive Services Task Force. Screening for prediabetes and type 2 diabetes in children and adolescents: US Preventive Services Task Force recommendation statement. JAMA. 2022;328(10):963-967.
8. US Preventive Services Task Force. Screening for obesity in children and adolescents: US Preventive Services Task Force recommendation statement. JAMA. 2017;317(23):2417-2426.
9. American Academy of Pediatrics. Recommendations for Preventive Pediatric Health Care. Accessed November 28, 2023. https://downloads.aap.org/AAP/PDF/periodicity_schedule.pdf?_ga=2.231878815.1413452381.1668206139-1862393775.1661884606
10. Hampl SE, Hassink SG, Skinner AC, et al. Clinical practice guideline for the evaluation and treatment of children and adolescents with obesity. Pediatrics. 2023;151(2):e2022060640.
11. 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):411-421.
12. American Psychological Association. Clinical Practice Guideline for Multicomponent Behavioral Treatment of Obesity and Overweight in Children and Adolescents: Current State of the Evidence and Research Needs. 2018. Accessed November 28, 2023. https://www.apa.org/obesity-guideline/clinical-practice-guideline.pdf
13. Committee on Adolescent Health Care. Committee opinion no. 714: obesity in adolescents. Obstet Gynecol. 2017;130(3):e127-e40.
14. Society for Adolescent Health and Medicine. Preventing and treating adolescent obesity: a position paper of the Society for Adolescent Health and Medicine. J Adolesc Health. 2016;59(5):602-606.
15. NAPNAP. NAPNAP position statement on the identification and prevention of overweight and obesity in the pediatric population. J Pediatr Health Care. 2021;35(4):425-427.
16. Polfuss ML, Duderstadt KG, Kilanowski JF, Thompson ME, Davis RL, Quinn M. Childhood obesity: evidence-based guidelines for clinical practice--part one. J Pediatr Health Care. 2020;34(3):283-290.

Abbreviations: BMI=body mass index; USPSTF=U.S. Preventive Services Task Force.

To fulfill its mission to improve health by making evidence-based recommendations for preventive services, the USPSTF routinely highlights the most critical evidence gaps for making actionable preventive services recommendations. We often need additional evidence to create the strongest recommendations for everyone and especially for persons with the greatest burden of disease.

In this table, we summarize key bodies of evidence needed for the USPSTF to make recommendations for interventions for high BMI in children and adolescents. For each of the evidence gaps listed below, research must be inclusive of populations with a high prevalence of high BMI, including Hispanic/Latino, Native American/Alaska Native, and non-Hispanic Black children and adolescents.