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Whitlock EP, O'Conner EA, Williams SB, et al. Effectiveness of Primary Care Interventions for Weight Management in Children and Adolescents: An Updated, Targeted Systematic Review for the USPSTF [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2010 Jan. (Evidence Syntheses, No. 76.)

2Methods

Methods Synopsis

Using the methods of the USPSTF,70 we developed three key questions (KQ) (with six sub-key questions) and an analytic framework (Figure 3) in conjunction with members of the USPSTF to update its 2005 recommendation on Screening for Childhood Overweight and Obesity. These KQs were designed to evaluate the effectiveness and safety of behavioral and pharmacological treatments for overweight and/or obese children. Key question 1 evaluates the effectiveness of interventions in reducing or stabilizing weight in the short-term (6–12 months since enrolling in treatment), while KQ2 focuses on the maintenance of BMI improvements through medium-term (between 1 to 5 years since enrollment and at least 12 months since treatment ended). Key question 3 assesses adverse effects of behavioral and pharmacological interventions. Key questions 1a and 2a consider other beneficial outcomes arising from the interventions. Key questions 1b, 2b, 1c, and 2c address whether specific program components and population or environmental factors can be identified among effective weight management programs.

Figure 3. Analytic framework and key questions.

Figure 3

Analytic framework and key questions. Key Questions (KQ) KQ1. Do weight management programs (behavioral, pharmacological) lead to BMI, weight, or adiposity stabilization or reduction in children and adolescents who are obese (≥ 95th BMI percentile) (more...)

We initially searched for systematic reviews and selected relevant, good quality systematic reviews where available to assist in conducting our literature search. A 2006 comprehensive National Institute of Health and Clinical Excellence (NICE) report was based on a series of systematic reviews and addressed the prevention and management of obesity in adults and children.9 Relevant portions of this report served as a basis for the primary search for the literature included in the current report. Since the NICE report only included orlistat and sibutramine, we used another good-quality review of pharmacological treatments54 as the basis for our search for pharmacological treatments. We conducted update searches in Ovid MEDLINE®, PsycINFO, Database of Abstracts of Reviews of Effects, the Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, and Education Resources Information Center from 2005 (2003 for pharmacological treatments) to June 10, 2008 to identify literature that was published after the search dates of these reports (Appendix A Table 1). We also hand-searched the reference lists of other good-quality reviews of childhood obesity treatment,2,7,48,71,72 received suggestions from experts, and searched reference lists of included trials and other relevant reviews and articles. We did not search for data from non-peer-reviewed sources or in non-English literature.

Two investigators independently reviewed 2786 abstracts and 369 articles against specified inclusion/exclusion criteria for each key question. Discrepancies were resolved by consensus. Detailed inclusion/exclusion criteria can be found in Appendix A Table 2. Briefly, we included controlled trials in primary care-relevant settings published in 1985 or later designed to promote weight loss or maintenance in overweight or obese 2 to 18 year-olds. We excluded studies of children with idiosyncratic weight management issues due to behavioral, cognitive, or medical factors. Trials were required to report weight outcomes of at least 6 months, although we included immediate harms when these were also reported. Trials were required to have a minimal intervention, attention control, usual care, placebo, or no-treatment control group and randomize at least 10 participants in each arm. For KQ3 (harms), we abstracted all reports of harms or potential harms in included studies. In addition, weight management programs reporting adverse events resulting in death, hospitalization, or need for urgent medical or psychiatric treatment were included even if they did not meet the minimum 6-month followup required for the other key questions. We examined other beneficial outcomes (KQ1a and KQ2a), important components of care (KQ1b and KQ2b) and population or environmental factors (KQ1c and KQ3c) using trials that were included for KQ1 (short-term efficacy) or KQ2 (maintenance efficacy). Based on prior literature,2,10,48,73,74 we limited our examination of specific intervention components (KQ1b and KQ2b) to the use of organized physical activity sessions, behavioral management techniques, and parental or family involvement. Details of how these components were coded can be found in Appendix A Detailed Methods.

One investigator abstracted data from included studies into evidence tables. A second investigator verified the evidence tables’ content. Two investigators independently quality rated all studies using established design-specific criteria (Appendix A Table 3). Discrepancies were resolved by consensus or consultation with a third investigator. Poor-quality studies were excluded.

Among behavioral trials, hours of contact was calculated as a proxy for treatment intensity and categorized as follows: very low (less than 10 hours), low (10 to 25 hours), medium (26 to 75 hours), and high (over 75 hours). Weight outcomes were categorized as short-term (6 to 12 months since beginning treatment) or maintenance (between 1 and 4 years after beginning treatment and at least 12 months after ending active treatment). In addition, we evaluated whether or not a treatment was comprehensive. Interventions were considered comprehensive if they included all of the following elements: (1) counseling for weight loss or healthy diet, (2) counseling for physical activity or provided a physical activity program, and (3) instruction in and support for the use of behavioral management techniques to help make and sustain changes in diet and physical activity. More detail about how these elements were operationalized can be found in Appendix A Detailed Methods.

Where possible, data were synthesized using quantitative methods. For most questions, however, we relied on qualitative synthesis due to significant heterogeneity in setting, age range, intervention approach, weight outcome reported, and timing of outcome reporting among the limited number of studies available for each type of intervention. We modeled typical cases to more clearly demonstrate the magnitude of weight change in pounds. In these cases, we used growth charts14 and on-line calculators75,76 provided by the Centers for Disease Control and Prevention (CDC) to estimate average height for age and to translate between percentile scores, BMI, percent overweight, kilograms, and pounds.

For the behavioral interventions, we conducted meta-analyses of short-term and maintenance outcomes separately. We focused on the change in BMI from baseline as the preferred measure of weight change when it was available. If BMI change was unavailable and could not be calculated or obtained from the author, we used change in BMI SDS as our second choice, and change in percent overweight as the third choice. Because we combined different outcomes, we analyzed standardized effect sizes. We also ran a meta-analysis examining only those reporting BMI change and found that that pattern of results and magnitude of effects were very similar to those seen in the primary meta-analysis that included all trials (and allowed different measures of weight change). All meta-analyses were conducted using RevMan 4.2. We did not quantitatively pool the results of the pharmacological trials due to the heterogeneity in the specific drug studied, length of treatment, and length of follow-up, in addition to differences in how outcomes were reported.

USPSTF Involvement

The authors worked with four USPSTF liaisons at key points throughout the review process to develop and refine the analytic framework and key questions, resolve issues around scope and approach, and will work with them to finalize this draft report. Research was funded by the Agency for Healthcare Research and Quality (AHRQ) under a contract to support the work of the USPSTF and AHRQ staff provided oversight throughout the project.

Cover of Effectiveness of Primary Care Interventions for Weight Management in Children and Adolescents
Effectiveness of Primary Care Interventions for Weight Management in Children and Adolescents: An Updated, Targeted Systematic Review for the USPSTF [Internet].
Evidence Syntheses, No. 76.
Whitlock EP, O'Conner EA, Williams SB, et al.

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