NIHR Signal Simple approaches to weight management of children and adolescents in primary care may not work

Published on 8 November 2016

Brief education and motivational interventions delivered by primary care professionals in several short consultations had only a marginal effect on weight loss among overweight or mildly obese children and young people.

Obesity can cause immediate health and wellbeing issues in children but also has significant implications for their long term health. Given that many of these health problems will present in a primary care setting, commissioners have been interested in primary care based programmes to tackle obesity and the “intensity” of the intervention required to make a difference.

The findings that a few sessions in primary care are ineffective, are consistent with current guidance which recommends a joined up approach to managing childhood obesity. The guidance emphasises specialist weight management programmes, complemented by support delivered within primary care. Identification and referral of obese children and young people to such programmes should be a priority to prevent long term consequences of obesity.

Share your views on the research.

Why was this study needed?

According to the Health Survey for England 2014, 17% of children aged two to 15 are obese and a further 14% are overweight. Children who are overweight or obese can experience bullying and low self-esteem which can lead to anxiety and depression and they are also much more likely to be obese as adults. Obesity can also cause high blood pressure, fatty deposits in arteries and raised cholesterol, which increase the risk of long term conditions, such as type 2 diabetes.

Obesity can be hard to treat effectively. National and local strategies set out a range of prevention and treatment interventions. It is important to understand what interventions may work in different contexts to invest resources appropriately. Earlier research explored different treatments in children, including diets, behavioural interventions, parental support and surgery.

This study adds to the evidence base by focusing on the value of treatment in primary care.

What did this study do?

This meta-analysis included 12 studies comparing the effects of weight management interventions in primary care with usual care, no intervention or feedback on weight only.  Ten were randomised controlled trials and two were quasi-experimental studies.  Interventions included motivational interviewing, solution-focused therapy approaches and dietary education. The number of sessions was small, varying from one to six. Follow-up ranged from one month to three years, though five studies had none. Those delivering the interventions were all based in primary care. That is they were mainly GPs and practice nurses.

The studies were conducted in the US, Australia, Israel and Turkey, so the results may not be generalizable to the UK. The studies were also at high risk of bias as they had relatively small sample sizes, short follow up periods and in some instances, a considerable number of participants were lost to follow up. These may have reduced the chance that this review could have shown a meaningful difference.

What did it find?

  • The overall change in BMI z score was measured as 0.04, which is a tiny change.The researchers suggest a reduction of 0.5 to 0.6 would be required to demonstrate “clear fat reduction and associated health benefit”.
  • There was no evidence of negative effects of weight management on body satisfaction; child or parent reported quality of life or self-worth. However, only three studies reported on this so the data on side effects was very limited.
  • There was no difference in the effects on participants by age; intensity or duration of the intervention; inclusion of telephone calls; or the involvement of parents in the intervention.

What does current guidance say on this issue?

NICE recommends a multi-agency approach to planning and commissioning weight management programmes for children and young people. They advocate specialist family-based interventions delivered by multidisciplinary teams, including a dietician, physical activity specialist, behaviour change expert, psychologist and paediatric specialist. Primary care has a role in referring children to a specialist programme; monitoring and providing on-going support to help sustain weight loss.

NICE estimates the cost to be around £8,400 per 100,000 population, or £320 per child attending a weight management program. They estimate potential long term savings if weight loss is maintained and the risk of obesity-related conditions is reduced.

What are the implications?

These findings suggest brief programmes based entirely in primary care do not work in this format. Children are more likely to lose weight if referred to a specialist programme delivered by a multidisciplinary team.

Commissioners investing in weight management will need to consider the role of primary care, which might involve referral, weight monitoring and longer term support.

Health services in general are moving towards more integrated working and this study suggests a more collaborative approach including more intensive and longer interventions may offer better value.

Citation and Funding

Sim LA, Lebow J, Wang Z et al. Brief primary care obesity interventions: a meta-analysis. Pedatrics. 2016;64(624):e434-e439.

No external funding received.

Bibliography

Craig R, Fuller E and Mindell J (eds).  Health survey for England 2014: health, social care and lifestyles. London: Health Information and Social Care Centre; 2015.

Dinsdale H, Ridler C and Ells L. A simple guide to classifying body mass index in children.  Oxford: National Obesity Observatory; 2011.

NICE. Managing overweight and obesity among children and young people: lifestyle weight management services. PH47 Costing Report. London: National Institute for Health and Care Excellence; 2013.

NICE. Weight management: lifestyle services for overweight or obese children and young people. PH47.London: National Institute for Health and Care Excellence; 2013.

Why was this study needed?

According to the Health Survey for England 2014, 17% of children aged two to 15 are obese and a further 14% are overweight. Children who are overweight or obese can experience bullying and low self-esteem which can lead to anxiety and depression and they are also much more likely to be obese as adults. Obesity can also cause high blood pressure, fatty deposits in arteries and raised cholesterol, which increase the risk of long term conditions, such as type 2 diabetes.

Obesity can be hard to treat effectively. National and local strategies set out a range of prevention and treatment interventions. It is important to understand what interventions may work in different contexts to invest resources appropriately. Earlier research explored different treatments in children, including diets, behavioural interventions, parental support and surgery.

This study adds to the evidence base by focusing on the value of treatment in primary care.

What did this study do?

This meta-analysis included 12 studies comparing the effects of weight management interventions in primary care with usual care, no intervention or feedback on weight only.  Ten were randomised controlled trials and two were quasi-experimental studies.  Interventions included motivational interviewing, solution-focused therapy approaches and dietary education. The number of sessions was small, varying from one to six. Follow-up ranged from one month to three years, though five studies had none. Those delivering the interventions were all based in primary care. That is they were mainly GPs and practice nurses.

The studies were conducted in the US, Australia, Israel and Turkey, so the results may not be generalizable to the UK. The studies were also at high risk of bias as they had relatively small sample sizes, short follow up periods and in some instances, a considerable number of participants were lost to follow up. These may have reduced the chance that this review could have shown a meaningful difference.

What did it find?

  • The overall change in BMI z score was measured as 0.04, which is a tiny change.The researchers suggest a reduction of 0.5 to 0.6 would be required to demonstrate “clear fat reduction and associated health benefit”.
  • There was no evidence of negative effects of weight management on body satisfaction; child or parent reported quality of life or self-worth. However, only three studies reported on this so the data on side effects was very limited.
  • There was no difference in the effects on participants by age; intensity or duration of the intervention; inclusion of telephone calls; or the involvement of parents in the intervention.

What does current guidance say on this issue?

NICE recommends a multi-agency approach to planning and commissioning weight management programmes for children and young people. They advocate specialist family-based interventions delivered by multidisciplinary teams, including a dietician, physical activity specialist, behaviour change expert, psychologist and paediatric specialist. Primary care has a role in referring children to a specialist programme; monitoring and providing on-going support to help sustain weight loss.

NICE estimates the cost to be around £8,400 per 100,000 population, or £320 per child attending a weight management program. They estimate potential long term savings if weight loss is maintained and the risk of obesity-related conditions is reduced.

What are the implications?

These findings suggest brief programmes based entirely in primary care do not work in this format. Children are more likely to lose weight if referred to a specialist programme delivered by a multidisciplinary team.

Commissioners investing in weight management will need to consider the role of primary care, which might involve referral, weight monitoring and longer term support.

Health services in general are moving towards more integrated working and this study suggests a more collaborative approach including more intensive and longer interventions may offer better value.

Citation and Funding

Sim LA, Lebow J, Wang Z et al. Brief primary care obesity interventions: a meta-analysis. Pedatrics. 2016;64(624):e434-e439.

No external funding received.

Bibliography

Craig R, Fuller E and Mindell J (eds).  Health survey for England 2014: health, social care and lifestyles. London: Health Information and Social Care Centre; 2015.

Dinsdale H, Ridler C and Ells L. A simple guide to classifying body mass index in children.  Oxford: National Obesity Observatory; 2011.

NICE. Managing overweight and obesity among children and young people: lifestyle weight management services. PH47 Costing Report. London: National Institute for Health and Care Excellence; 2013.

NICE. Weight management: lifestyle services for overweight or obese children and young people. PH47.London: National Institute for Health and Care Excellence; 2013.

Brief Primary Care Obesity Interventions: A Meta-analysis

Published on 14 September 2016

Sim, L. A.,Lebow, J.,Wang, Z.,Koball, A.,Murad, M. H.

Pediatrics , 2016

CONTEXT: Although practice guidelines suggest that primary care providers working with children and adolescents incorporate BMI surveillance and counseling into routine practice, the evidence base for this practice is unclear. OBJECTIVE: To determine the effect of brief, primary care interventions for pediatric weight management on BMI. DATA SOURCES: Medline, CENTRAL, Embase, PsycInfo, and CINAHL were searched for relevant publications from January 1976 to March 2016 and cross-referenced with published studies. STUDY SELECTION: Eligible studies were randomized controlled trials and quasi-experimental studies that compared the effect of office-based primary care weight management interventions to any control intervention on percent BMI or BMI z scores in children aged 2 to 18 years. DATA EXTRACTION: Two reviewers independently screened sources, extracted data on participant, intervention, and study characteristics, z-BMI/percent BMI, harms, and study quality using the Cochrane and Newcastle-Ottawa risk of bias tools. RESULTS: A random effects model was used to pool the effect size across eligible 10 randomized controlled trials and 2 quasi-experimental studies. Compared with usual care or control treatment, brief interventions feasible for primary care were associated with a significant but small reduction in BMI z score (-0.04, [95% confidence interval, -0.08 to -0.01]; P = .02) and a nonsignificant effect on body satisfaction (standardized mean difference 0.00, [95% confidence interval, -0.21 to 0.22]; P = .98). LIMITATIONS: Studies had methodological limitations, follow-up was brief, and adverse effects were not commonly measured. CONCLUSIONS: BMI surveillance and counseling has a marginal effect on BMI, highlighting the need for revised practice guidelines and the development of novel approaches for providers to address this problem.

Body mass index (BMI) is a well-used indicator of obesity. However, children grow at different rates, which makes it difficult to measure BMI accurately. Accordingly, variable ranges are used, representing average values for boys and girls at different ages. In this study, the researchers use BMI z scores. These z scores indicate the extent to which a child’s BMI is above or below average for their age and sex.  For example, a z score of 1.5 indicates the BMI is 1.5 standard deviations above average and a score of -1.5 that the BMI is 1.5 standard deviations below average.

Expert commentary

The high prevalence of childhood overweight/obesity in the UK and many other countries continues to cause concern in terms of overall population health and economic burden on already over-stretched health services. Primary care interventions to address this problem seem attractive, both for families (ease and equity of access) and for economic reasons.

However, this meta-analysis by Sim et al. of relatively 'low-grade' lifestyle interventions demonstrates minimal effects in terms of weight improvement and no effect on body satisfaction. The tiny improvement of BMI z scores will have no effect on metabolic health and likely reflects a regression to the mean. What is on offer currently is simply not working. We need to rethink our intervention strategies if we hope to see any long-term benefits.

Julian Hamilton-Shield, Professor of Diabetes and Metabolic Endocrinology & Consultant Paediatrician, University of Bristol