Dangerous USPSTF Guidelines for Higher-Weight Children Are Open for Public Comment - Part 1

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The US Preventive Services Task Force has put out their draft recommendation for higher-weight children. It is open for public comment until January 16. I’ve been fully immersed in it since the moment that I knew about it yesterday (their evidence synthesis is 381 pages long!)

Full disclosure: I was asked and participated in the early stages of this as an expert interviewee and they were very respectful. I have no way of knowing if I influenced the report at all, and even if I did I certainly wish I had been much more successful.

Today I’ll give a quick overview and some short(ish) sample answers to the evidence review public comment questions, next week I’ll do a deep dive into the evidence synthesis and sample answers for the Draft recommendations statement public comment.

I do want to note that if you are going to make a public comment, you want it to be individual, so feel free to quote anything I say here, but you’ll want to add your own words, information, and experiences.

Ok, let’s start with a very quick breakdown:

The good news
(there’s not a lot, and the bar is low, but at least there’s some, especially given the even more disastrous AAP Guidelines.)

They aren’t recommending intensive dieting to toddlers.

They aren’t recommending diet drugs to children.

They acknowledge the need for research around weight-neutral interventions.

The bad news

They are recommending intensive diet programs (which they call “comprehensive, intensive behavioral interventions) to any child 6 or older whose BMI is greater than
or equal to the 95^th percentile based on charts of kids’ weights from over twenty years ago.

They excluded any existing research on weight-neutral interventions, fencing themselves in so that weight loss could be their only recommendation.

Their recommendations are based on studies rated “fair” or “good” (Only “poor” studies were excluded) Only nine of the included studies managed a “good” rating, meaning the majority of the evidence on which this recommendation is based is only fair.

Their recommendation is based on studies that offer almost no follow-up beyond 13 months which is not nearly enough time to capture weight regain or long-term physical or psychological harm.

Their recommendation is not based on standardized interventions - the studies on which this is based varied significantly.

They claim their short-term research suggests that no harm comes from these interventions but, in an entirely separate section, acknowledge that they don’t even have two years of data on what happens to kids after these interventions in terms of psychological harm or weight regain/weight cycling.

As you may imagine, I strongly disagree with the recommendation and believe that it will cause significant harm to the children and adolescents who are subjected to these interventions – harm that will either continue to go uncaptured in research and/ or will be blamed on the children, their families, and/or their weight rather than on the interventions foisted upon them by people (however well-meaning) who are supposed to be focused on supporting their health but who have become completely distracted by a focus on making them thin.

Here are some sample answers to the Draft Evidence Review public comment questions, again feel free to use/quote any of this, but please make sure to also use your own words and experiences. I’ll be providing a much more in-depth analysis next week on which I’ll base my final answers.

EDIT: In my original post I did not make it clear that the group who compiled the evidence synthesis (Kaiser Permanente Evidence-based Practice Center, Kaiser Permanente Center for Health Research) did not actually vote on the guidelines. Voting on the guidelines was only by USPSTF members. Also, I’ve learned that it is best to direct critiques of the *recommendation* to the recommendation statement rather than the evidence review for greatest effect so if you have limited time, you can find that information and feedback form here.

Do you think this report includes all of the relevant studies?

No.

Please share citations for the studies you believe should be added.

In general, the report should include research around weight-neutral health-supporting interventions, and should have done a better job of citing research that shows harm associated with these interventions.

Neumark-Sztainer, D., Wall, M., Story, M., & Standish, A. R. (2012). Dieting and unhealthy weight control behaviors during adolescence: associations with 10-year changes in body mass index. The Journal of adolescent health : official publication of the Society for Adolescent Medicine, 50(1), 80–86. https://doi.org/10.1016/j.jadohealth.2011.05.010

None of the behaviors being used by adolescents for weight-control purposes predicted weight loss…

Of greater concern were the negative outcomes associated with dieting and the use of unhealthful weight-control behaviors…including eating disorders and weight gain

Dugmore, J. A., Winten, C. G., Niven, H. E., & Bauer, J. (2020). Effects of weight-neutral approaches compared with traditional weight-loss approaches on behavioral, physical, and psychological health outcomes: a systematic review and meta-analysis. Nutrition reviews, 78(1), 39–55. https://doi.org/10.1093/nutrit/nuz020

Weight-neutral approaches may be as effective as weight-loss methods for improving physical, psychological, and behavioral outcomes.

Ulian, M. D., Aburad, L., da Silva Oliveira, M. S., Poppe, A. C. M., Sabatini, F., Perez, I., Gualano, B., Benatti, F. B., Pinto, A. J., Roble, O. J., Vessoni, A., de Morais Sato, P., Unsain, R. F., & Baeza Scagliusi, F. (2018). Effects of health at every size® interventions on health-related outcomes of people with overweight and obesity: a systematic review. Obesity reviews : an official journal of the International Association for the Study of Obesity, 19(12), 1659–1666. https://doi.org/10.1111/obr.12749

The HAES® interventions benefited both the psychological and physical activity outcomes, besides promoting behavioural and qualitative changes in eating habits

Raffoul, A., & Williams, L. (2021). Integrating Health at Every Size principles into adolescent care. Current opinion in pediatrics, 33(4), 361–367. https://doi.org/10.1097/MOP.0000000000001023

Current weight-focused interventions have not demonstrated any lasting impact on overall adolescent health… The impacts of intentional weight loss in the critical period of adolescence are well documented and of significant concern for overall health [7]. As an alternative, HAES-informed care can strengthen the rapport between adolescents and health providers, as well as encourage engagement in healthful behaviors outside of achieving weight loss. Further research is needed to assess the effectiveness of HAES-informed interventions versus traditional weight-focused interventions among adolescents [4&&]. However, the integration of HAES principles into adolescent care presents minimal risk and has significant implications for patient-centered care.

Pinhas, L., McVey, G., Walker, K. S., Norris, M., Katzman, D., & Collier, S. (2013). Trading health for a healthy weight: the uncharted side of healthy weights initiatives. Eating disorders, 21(2), 109–116. https://doi.org/10.1080/10640266.2013.761082

Ob*sity-prevention programs that push “healthy eating” are triggering disordered eating in some children, creating sudden neuroses around food in children who never before worried about their weight

Do you agree with how the studies and the overall data have been interpreted?

No.

The report should be revised in the following ways

Most importantly:
The report should acknowledge that there is insufficient data to recommend intensive behavioral interventions. Too much harm can come from recommendations based only on short-term studies (per the report’s own analysis “Data on behavioral interventions were extremely limited beyond 12 to 13 months… Maintenance of weight changes beyond one year are unknown”) with a combined 8,798 total subjects broken down into much smaller subject groups in individual studies, who underwent non-standardized interventions.

For example, the report could note that, given that about a century of data on adults shows that the vast majority regain the weight that they lost in year one between years two and five, the lack of long-term follow-up alone is enough to acknowledge that an evidence-based recommendation cannot be ethically made at this time.

At the very least:

If the USPSTF insists on making a recommendation, it should be downgraded from B to D based on the short duration, small sample sizes, and heterogeneity of the studies upon which the recommendation is based.

The report should acknowledge the serious limitations of “diagnosing” children with a health issue requiring costly, time-consuming “intensive” intervention soley based on a comparison of their weight to the weight of children 20 years ago (actively ignoring the natural diversity of body sizes.)

The report should acknowledge that a myopic focus on weight loss to the exclusion of weight-neutral interventions in the research plan biases the evidence synthesis  such that weight loss, no matter how small or short-term is seen as worthy of a wide-scale recommendation, despite the finding of minimal health impacts, compounded by the fact that there is no attempt to separate the benefits of behavior changes from those of the (small, likely temporary) weight loss (especially given research in adults that has found that the weight loss could not be connected to health benefits ween after dieting (https://compass.onlinelibrary.wiley.com/doi/abs/10.1111/spc3.12076 )

The sentence “In the short term, weight management interventions led to lower weight in children and adolescents with [moderate] effects [for behavioral interventions] with no evidence of serious harm and small to no impact on health, behavioral, or intermediate cardiometabolic outcomes” should be followed by “and so we find that the evidence is insufficient to recommend behavioral interventions, given the lack of data (and lack of attempts at gathering data) around weight regain and weight cycling as well as risks of disordered eating and eating disorders.

Finally, the report claims that “the USPSTF is committed to mitigating the health inequities that prevent many people from fully benefiting from preventive services” but chooses not to take the costs into account. The report should be clear that asking parents and guardians to get their children to 26 appointments, including everything from paying for the program to having the time and transportation with the likely outcome of only a small amount of weight loss, and even smaller chance of health improvements, and the complete lack of data to suggest that either will be long-term can do nothing but reinforce existing inequities.

I want to note that while I do believe that the USPSTF recommendation will do significant harm to the children and adolescents who are subjected to these interventions, I do not think that is due to malicious intent on the part of those involved in the report. Rather, I believe it is an extension of a culture, including healthcare culture, that that is willing to risk the lives and quality of life of higher-weight people, including children, for the slightest chance of the smallest amount of the shortest-term weight loss.

What could be done to make the findings in this report clearer?

The choice to exclude research that focuses on weight-neutral health-supporting interventions invalidates any findings. Without examining the research around supporting the health of children of all sizes directly, rather than trying to manipulate the size of some children, the entire report is predicated on a myopic focus on weight loss as the only appropriate intervention. Absent a comparison between weight-neutral health-supporting interventions and body size manipulation attempts, there is no way to know if any health benefits that may be correlated with these weight loss interventions are achievable through weight-neutral interventions with less risk of weight cycling and eating disorders and without the child’s healthcare system investing in the inherently body-shaming idea that their body itself is wrong and must be fixed through intensive interventions whose goal is focused on changing their size and not their health.

Adding to the danger is the report’s choice to claim a lack of harm based on a lack of research, will actively excluding research (some of which I’ve included below) as well as the lived experience of many higher-weight adults that speaks to the harm that these interventions can create.

The report could be honest that there is inadequate data upon which to base a recommendation. The report could point out that evidence of short-term weight loss in no way predicts long-term maintenance and that given the known dangers of weight cycling and the risk of perpetuating eating disorders, the USPSTF cannot recommend weight loss interventions for children and adolescents at this time.

Instead of recommending an intervention based on predominantly “fair” quality heterogenous short-term studies, the report could focus on the research that is needed including long-term assessments of weight loss interventions begun in childhood in terms of both weight regain and associated harms.

The “Research Needs and Gaps” section makes it clear that the existing research is inadequate to support the recommendation.

That section should also be made more robust -  two years is an inadequate length to determine long-term impacts of these interventions and the long-term impacts matter. Five years would be the absolute least that would be appropriate (given all of the research that shows weight regain in adults between years two and five.)

Another major research need/gap is research that captures the experiences of adults who were subjected to weight loss interventions as children.

Here are the links to check this out for yourself, please feel free to leave any thoughts in the comments:

Links:

Full recommendation: https://www.uspreventiveservicestaskforce.org/uspstf/draft-recommendation/high-body-mass-index-children-adolescents-interventions#fullrecommendationstart

Page for draft evidence review public comment: https://www.uspreventiveservicestaskforce.org/uspstf/high-bmi-children-adolescents-interventions-draft-evidence-review

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More research and resources:
https://haeshealthsheets.com/resources/

*Note on language: I use “fat” as a neutral descriptor as used by the fat activist community, I use “ob*se” and “overw*ight” to acknowledge that these are terms that were created to medicalize and pathologize fat bodies, with roots in racism and specifically anti-Blackness. Please read Sabrina Strings’ Fearing the Black Body – the Racial Origins of Fat Phobia and Da’Shaun Harrison’s Belly of the Beast: The Politics of Anti-Fatness as Anti-Blackness for more on this.