A group within the US Department of Health and Human Services called the US Preventive Services Task Force (USPSTF – for those who enjoy acronyms) just published a set of recommendations that strongly endorse the value of treating childhood and adolescent obesity with intensive CBT treatments. This note provides a description of this group, a summary of key conclusions, an historical perspective on this new set of recommendations relative to two other sets of recommendations, and a bottom line recommendation for you to consider.
Here is the scoop on USPSTF, check out this website for additional details and a list of the current members of this group: http://www.ahrq.gov/clinic/uspstfab.htm <http://www.ahrq.gov/clinic/uspstfab.htm>
About USPSTF: As you’ll see from the information below, this is a very medically oriented group. At the time this report was finalized it consisted of 16 people– primarily academic primary care physicians and administrators– not primarily researchers, but practitioners and teachers at university medical centers. Several of them do a fair amount of research, but I do not believe any of them specializes in research on obesity.
The U.S. Preventive Services Task Force (USPSTF), first convened by the U.S. Public Health Service in 1984, and since 1998 sponsored by the Agency for Healthcare Research and Quality (AHRQ), is the leading independent panel of private-sector experts in prevention and primary care. The USPSTF conducts rigorous, impartial assessments of the scientific evidence for the effectiveness of a broad range of clinical preventive services, including screening, counseling, and preventive medications. Its recommendations are considered the “gold standard” for clinical preventive services. The mission of the USPSTF is to evaluate the benefits of individual services based on age, gender, and risk factors for disease; make recommendations about which preventive services should be incorporated routinely into primary medical care and for which populations; and identify a research agenda for clinical preventive care. Background and Mission <http://www.ahrq.gov/clinic/uspstfab.htm#Background#Background> / Process <http://www.ahrq.gov/clinic/uspstfab.htm#Process#Process> / Members of the USPSTF <http://www.ahrq.gov/clinic/uspstfab.htm#Members#Members> / Role of AHRQ Staff <http://www.ahrq.gov/clinic/uspstfab.htm#Role#Role> / Role of Partners <http://www.ahrq.gov/clinic/uspstfab.htm#Partners#Partners> / Impact of the USPSTF <http://www.ahrq.gov/clinic/uspstfab.htm#Impact#Impact> / For More Information <http://www.ahrq.gov/clinic/uspstfab.htm#Information#Information>
Background and Mission: Public Law Section 915 mandates that AHRQ convene the USPSTF to conduct scientific evidence reviews of a broad array of clinical preventive services, develop recommendations for the health care community, and provide ongoing administrative, research, technical, and dissemination support. The Task Force’s pioneering efforts began with the 1989 Guide to Clinical Preventive Services. A second edition of the Guide was published in 1996. The current Guide to Clinical Preventive Services <http://www.ahrq.gov/clinic/pocketgd.htm> is available on the Web. Return to Contents <http://www.ahrq.gov/clinic/uspstfab.htm#contents#contents>
Process: The Task Force makes its recommendations on the basis of explicit criteria. Recommendations issued by the USPSTF are intended for use in the primary care setting. The USPSTF recommendation statements present health care providers with information about the evidence behind each recommendation, allowing clinicians to make informed decisions about implementation.* <http://www.ahrq.gov/clinic/uspstfab.htm#asterisk#asterisk> The USPSTF is supported by an Evidence-based Practice Center <http://www.ahrq.gov/clinic/epc/> (EPC). Under contract to AHRQ, the EPC conducts systematic reviews of the evidence on specific topics in clinical prevention that serve as the scientific basis for USPSTF recommendations. The USPSTF reviews the evidence, estimates the magnitude of benefits and harms for each preventive service, reaches consensus about the net benefit for each preventive service, and issues a recommendation. The Task Force grades the strength of the evidence from “A” (strongly recommends), “B” (recommends), “C” (no recommendation for or against), “D” (recommends against), or “I” (insufficient evidence to recommend for or against).
*From: Harris RP, Helfand M, Woolf SH, et al. Current methods of the U.S. Preventive Services Task Force: a review of the process. Am J Prev Med 2001;20(suppl 3):21-35.
The primary conclusions reached in their 2010 recommendations:
a. Screen children aged 6 yr and older for obesity (using BMI standards). Offer or refer for intensive counseling and behavioral interventions. They defined “intensive” as moderate or high levels of contact with professionals (moderate = 26-75 hours; high = >75 hours). “Behavioral interventions” means CBT. Counseling in this case refers to teaching about nutritional and physical activities. They gave this recommendation a grade of “B.” That means that “there is a high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial.” In other words, DO IT – IT HELPS A LOT OF PEOPLE MOST OF THE TIME!
b. Lower intensity interventions (e.g., educational counseling alone about diet and activity) did not demonstrate “a significant consistent benefit.” In other words, just working with a dietitian or a trainer for relatively limited periods of time (even as many as 24 sessions) does not work.
c. The risk of harm of these intensive interventions is small. They found “no evidence of adverse effects on growth, eating disorder pathology, or mental health” for these programs. Recall the recent debates in which Wellspring researchers were engaged about this in which we argued against others who stipulated that such treatments do increase risk of harm.
Perspective – other sets of recommendations: In 2005, this group (probably a similar group of academically oriented medical professionals put together by this branch of the Department of Health and Human Services) recommended that BMI screening was valid to assess obesity. However, they viewed the evidence of the effectiveness of CBT interventions for the treatment of childhood obesity as inadequate. Considering the number and quality of studies available at that time, I find that conclusion very surprising. On the other hand, remember that this group included folks who did not specialize in the treatment of obesity. Now, however, they view the evidence differently. They apparently commissioned a group of researchers to review the evidence for them (see reference 15). The current evidence overwhelmingly shows the benefits short term and long term of CBT interventions combined with nutrition and physical activity counseling. Two other sets of recommendations are attached. You may recall seeing the 2007 “Expert Panel” recommendations published in Pediatrics (as is the present set of recommendations). That group was comprised of representatives from 15 healthcare agencies, including the AMA and CDC. Note that the summary of that group’s recommendations focused on 4 stages of interventions, from educational ones to intensive treatments (including immersion treatment and surgery). That paper was 33 pages long and included 284 references. The present USPSTF recommendations is 6 pages long and includes 19 references. The former set of recommendations provided a much more detailed perspective on some of the relevant literature, but also agreed with the present group in advising that intensive CBT interventions are effective. Our 7 Steps summary paper (also attached) agreed more with the conclusions of the USPSTF recommendations by asserting that educational counseling alone is simply inadequate.
Bottom Line: All three of the attached sets of recommendations support the work that we do in Wellspring (Wellspring Camps, Wellspring Academies, see www.wellspringweightloss.com). We provide the most intensive and promising versions of counseling + CBT interventions available anywhere – with locations geographically convenient for most families in the USA, as well as for many in Canada and the UK.
Tags: Obesity, Weight Loss