New CME for doctors — What wasn’t said about childhood weight management
This past week, the American Academy of Family Physicians announced the release of its latest CME (continuing medical education) Bulletin for family doctors entitled, “Assessment, Prevention and Treatment of Childhood Obesity.” It exemplified the educational information doctors are being given about fat children and, more importantly, what they’re not.
This CME course will be familiar to regular readers, as it is the very same weight management guideline that was developed last year by the AMA Expert Committee brought together by Dr. William Dietz, M.D., Ph.D., of the Centers for Disease Control and Prevention and issued by the American Medical Association [reviewed here]. The medical editor of the AAFP course was a member of the AMA Expert Committee, Dr. Goutham Rao, M.D., clinical director of the Weight Management and Wellness Center at Children’s Hospital of Pittsburgh. Dr. Rao also authored the book, Child Obesity: A Parent's Guide to a Fit, Trim, and Happy Child (Prometheus Books, 2006). The other medical consultant for the AAFP course was Dr. Wendelin M. Slusser, M.D., MS, FAAP, founder and medical director of the UCLA Fit for Healthy Weight Program, which offers a weight loss clinic and bariatric surgery center for children and teens.
This CME course* begins by describing the epidemic of childhood obesity, including the decision by the AMA Expert Committee to change the definitions of child overweight, and label as ‘obese’ children with BMIs at or above the 95th percentile on new BMI growth curves, and as ‘overweight’ those at or above the 85th percentile. The CME paper goes on to attribute the childhood obesity epidemic to children’s behaviors: increased sedentary time, decreased physical activity and overeating energy-dense junk food. The CME course recommends doctors annually assess the BMIs of all pediatric patients, as well as conduct in-depth evaluations of the diets and lifestyle habits of children and their families, and “counsel all children about behaviors that can prevent excessive weight gain.”
According to the CME: “The AMA expert committee issued healthy lifestyle recommendations to prevent and treat childhood obesity based on a review of the available evidence and clinical experience.” Those healthy lifestyle strategies for successful weight control in children include: offer fruit first and then whole grains for breakfast; eliminate cereals with added sugar; put children on low-fat milk at age 1 and nonfat after age 2; serve children high water content foods like soups with lower calories to fill them up; reduce fruit juices, serve fruit and raw nuts for snacks; limit sweetened drinks and promote water throughout the day; limit meals away from home; control portion sizes; restrict screen time to 2 hours a day, setting “a timer to sound when the child’s screen time is up;” incorporate exercise into family routines and organize active play dates.
A staged treatment is then outlined, as previously described in detail, which gives the children 3 to 6 months to achieve the weight goals set for them or they are advanced to the next stage of structured weight management, each one increasingly more intensive. From age 2, children at or above the 85th percentile are targeted with interventions to stunt further growth until they fall off of their growth curve and drop below the 85th percentile.
Accompanying the weight management interventions for children are intense counseling for parents, which begin by getting them to “admit there is a problem” and ascertain their “readiness to change” their life style habits to correct the child’s overweight. “Motivational interviewing” is suggested. Parents who find it hard to make ‘healthy lifestyle changes,’ the CME course suggests, may benefit from referrals for counseling on their parenting skills or to provide weight management motivation.
Finally, “when all else fails,” the course says behavioral interventions should be augmented with diet drugs — sibutramine (Meridia) or orlistat (Alli, Xenical) — for adolescents. “Data are limited regarding bariatric surgery for obese pediatric patients, but some centers are also offering bariatric surgeries for teens, based on success with adult patients.”
Balancing the weight scale
Despite the AAFP’s assurances in its Disclosure Statement [see below] that this CME course has undergone extensive peer review to ensure balance in the content, a deficit of balance was evident. There was no review of the clinical evidence for the working assumptions on the causes of variances in children’s weights or the health implications, for the long-term effectiveness (on weight or health outcomes) of their recommended weight management interventions, or any risk analysis.
Physicians didn’t read the latest determinations, Screening and Interventions for Childhood Obesity, and summary of the evidence issued by the U.S. Preventive Services Task Force after examining 40 years of evidence, about 6,900 studies and abstracts. It found insufficient evidence to recommend screening for overweight in children and adolescents as a means to prevent adverse health problems. “It is not clear what BMI at any given age is associated with future good health,” the Childhood Obesity Working Group wrote in a follow-up article in the journal Pediatrics. “Evidence for effective interventions delivered in pediatric primary care settings are [sic] lacking.” Nor has the USPSTF found any evidence to support dietary counseling in primary care centers for children or adolescents to promote a healthy diet.
The USPSTF found no quality evidence that behavioral weight interventions improves health outcomes or physiological measures, and the limited clinical trial data on the effectiveness of any weight management interventions in young people was poor to fair. “We did not find adequate evidence meeting our criteria to address the impact of BMI screening and/or treatment of overweight (or at risk for overweight) on any of these risks factors or morbidities,” it stated. Most importantly, the USPSTF Childhood Obesity Working Group opposed the American Academy of Pediatrics and American Academy of Family Physicians for endorsing BMI assessments and using BMI growth curves to identify fat children for interventions. They cited the potentials for harm, adding: “The first principle of medicine is well known: primum non nocere (first, do no harm). If we forge ahead with an intervention (whether therapeutic, preventive, or even diagnostic) without knowing whether it is beneficial, we run the risk of causing unintentional harm.”
Test for the CME credit
The Self-Assessment Quiz to be completed by doctors to receive their 1 CME credit, was a multiple choice exam where the right answers sometimes appeared wrong and vice versa. To make it easy, though, they gave doctors the answers!
A version of this free CME course was also published in the July 1 issue of the journal American Family Physician, authored by Dr. Rao. It was also offered by Medscape online for CME credits on July 17, 2008.
For a different test in critical reading, see how carefully the text was worded in the Medscape version. For example: “Although type 2 diabetes in children was rare 2 decades ago, it now accounts for nearly one half of all new cases of diabetes among children in some settings.” Did you think you read what you really didn’t? [Review here and here.]
As with much research, the data that isn’t reported can be the most valuable. What is left unsaid can leave us with the impression that we fully understand an issue, rather than realize how little we really do.
© 2008 Sandy Szwarc
Disclosure Statements: Dr. Slusser, Dr. Rao, Ms. Stendardo [freelance writer] and Ms. Watkins [AAFP editor] have returned disclosure forms indicating that they have no financial interest in or affiliation with any commercial supporter or providers of any commercial services discussed in this educational material. Funding: The CME course was underwritten by WellPoint, Inc., which offers Blue Cross Blue Shield-licensed subsidiaries across the country, along with a family of managed health and prescription benefit management companies.
* AAFP Disclosure: It is the policy of the AAFP that all CME planning committees/faculty/authors/editors/staff disclose relationships with commercial entities upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflicts of interest and, if identified, they are resolved prior to confirmation of participation. Only those participants who had no conflict of interest or who agreed to an identified resolution process prior to their participation were involved in this CME activity. The AAFP uses an anonymous peer review process to evaluate the content of the CME Bulletins. This process ensures a clear resolution of any potential conflicts of interest, and guarantees the fairness and balance of the content.
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