Screening for Obesity and Intervention for Weight Management in Children and Adolescents

Importance  Obesity is common in children and adolescents in the United States, is associated with negative health effects, and increases the likelihood of obesity in adulthood.

Objective  To systematically review the benefits and harms of screening and treatment for obesity and overweight in children and adolescents to inform the US Preventive Services Task Force.

Data Sources  MEDLINE, PubMed, PsycINFO, Cochrane Collaboration Registry of Controlled Trials, and the Education Resources Information Center through January 22, 2016; references of relevant publications; government websites. Surveillance continued through December 5, 2016.

Study Selection  English-language trials of benefits or harms of screening or treatment (behavior-based, orlistat, metformin) for overweight or obesity in children aged 2 through 18 years, conducted in or recruited from health care settings.

Data Extraction and Synthesis  Two investigators independently reviewed abstracts and full-text articles, then extracted data from fair- and good-quality trials. Random-effects meta-analysis was used to estimate the benefits of lifestyle-based programs and metformin.

Main Outcomes and Measures  Weight or excess weight (eg, body mass index [BMI]; BMI zscore, measuring the number of standard deviations from the median BMI for age and sex), cardiometabolic outcomes, quality of life, other health outcomes, harms.

Results  There was no direct evidence on the benefits or harms of screening children and adolescents for excess weight. Among 42 trials of lifestyle-based interventions to reduce excess weight (N = 6956), those with an estimated 26 hours or more of contact consistently demonstrated mean reductions in excess weight compared with usual care or other control groups after 6 to 12 months, with no evidence of causing harm. Generally, intervention groups showed absolute reductions in BMI z score of 0.20 or more and maintained their baseline weight within a mean of approximately 5 lb, while control groups showed small increases or no change in BMI z score, typically gaining a mean of 5 to 17 lb. Only 3 of 26 interventions with fewer contact hours showed a benefit in weight reduction. Use of metformin (8 studies, n = 616) and orlistat (3 studies, n = 779) were associated with greater BMI reductions compared with placebo: −0.86 (95% CI, −1.44 to −0.29; 6 studies; I2 = 0%) for metformin and −0.50 to −0.94 for orlistat. Groups receiving lifestyle-based interventions offering 52 or more hours of contact showed greater improvements in blood pressure than control groups: −6.4 mm Hg (95% CI, −8.6 to −4.2; 6 studies; I2 = 51%) for systolic blood pressure and −4.0 mm Hg (95% CI, −5.6 to −2.5; 6 studies; I2 = 17%) for diastolic blood pressure. There were mixed findings for insulin or glucose measures and no benefit for lipids. Medications showed small or no benefit for cardiometabolic outcomes, including fasting glucose level. Nonserious harms were common with medication use, although discontinuation due to adverse effects was usually less than 5%.

Conclusions and Relevance  Lifestyle-based weight loss interventions with 26 or more hours of intervention contact are likely to help reduce excess weight in children and adolescents. The clinical significance of the small benefit of medication use is unclear.

Reference: JAMA. 2017;317(23):2427-2444.

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Effect of an Internet-Based Program on Weight Loss for Low-Income Postpartum Women

Question  Does an internet-based weight loss program promote long-term weight loss in low-income postpartum women in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC program)?

Findings  In this cluster randomized trial including 371 low-income postpartum women, an internet-based program plus the WIC program produced significantly greater weight loss over 12 months compared with the WIC program alone (3.2 kg vs 0.9 kg).

Meaning  Among low-income postpartum women, an internet-based weight loss program plus the WIC program compared with the WIC program alone resulted in significantly greater weight loss over 12 months. Future research is needed to determine cost-effectiveness.

Reference: JAMA. 2017;317(23):2381-2391.

High-Intensity Statins Guideline Expectations and Clinical Application

There have been major advances in the understanding and management of atherosclerotic cardiovascular disease (ASCVD). Central to these was the discovery of the role of cholesterol-containing lipoprotein particles in the atherosclerotic process and the development of lipid-lowering agents, particularly statins. Despite substantial and consistent evidence to support a causal link between statin use and prevention of ASCVD events, there is still debate regarding the appropriate administration of statins, particularly with regard to primary prevention.

Reference: JAMA. 2017;317(24):2543-2544.

Effect of Electroacupuncture on Urinary Leakage Among Women With Stress Urinary Incontinence

Question  Is electroacupuncture involving the lumbosacral region effective in reducing urine leakage for women with stress urinary incontinence?

Findings  In this randomized clinical trial that included 504 women, the mean decrease in urine leakage, measured by the 1-hour pad test from baseline to week 6, was 9.9 g with electroacupuncture vs 2.6 g with sham electroacupuncture, a significant difference.

Meaning  Among women with stress urinary incontinence, treatment with electroacupuncture involving the lumbosacral region, compared with sham electroacupuncture, resulted in less urine leakage after 6 weeks.

Reference: JAMA. 2017;317(24):2493-2501.

NSAIDs for Chronic Low Back Pain

Clinical Question  Are nonsteroidal anti-inflammatory drugs (NSAIDs) associated with greater pain relief than placebo, other drugs, and nondrug treatments for patients with chronic low back pain?

Bottom Line  Compared with placebo, NSAIDs are associated with a small but significant improvement in pain and disability in patients with chronic low back pain, although this difference became nonsignificant when studies with high risk for bias were excluded. The associated benefits were smaller than the minimal clinically important difference.

Reference: JAMA. 2017;317(22):2327-2328.

Association of Gestational Weight Gain With Maternal and Infant Outcomes

Question  What is the association between gestational weight gain above or below the Institute of Medicine guidelines and maternal and infant outcomes?

Findings  In this systematic review and meta-analysis of 1 309 136 pregnancies, gestational weight gain below recommendations (in 23% of women) was associated with higher risk of small for gestational age (odds ratio [OR], 1.53) and preterm birth (OR, 1.70) and lower risk of large for gestational age (OR, 0.59) and macrosomia (OR, 0.60). Gestational weight gain above recommendations (47%) was associated with lower risk of small for gestational age (OR, 0.66) and preterm birth (OR, 0.77) and higher risk of large for gestational age (OR, 1.85), macrosomia (OR, 1.95), and cesarean delivery (OR, 1.30).

Meaning  Gestational weight gain below or above the Institute of Medicine guidelines was associated with higher risk of some adverse maternal and infant outcomes.

Reference: JAMA. 2017;317(21):2207-2225.

Oral Glucocorticoid–Sparing Effect of Benralizumab in Severe Asthma

BACKGROUND

Many patients with severe asthma rely on oral glucocorticoids to manage their disease. We investigated whether benralizumab, a monoclonal antibody directed against the alpha subunit of the interleukin-5 receptor that significantly reduces the incidence of asthma exacerbations, was also effective as an oral glucocorticoid–sparing therapy in patients relying on oral glucocorticoids to manage severe asthma associated with eosinophilia.

METHODS

In a 28-week randomized, controlled trial, we assessed the effects of benralizumab (at a dose of 30 mg administered subcutaneously either every 4 weeks or every 8 weeks [with the first three doses administered every 4 weeks]) versus placebo on the reduction in the oral glucocorticoid dose while asthma control was maintained in adult patients with severe asthma. The primary end point was the percentage change in the oral glucocorticoid dose from baseline to week 28. Annual asthma exacerbation rates, lung function, symptoms, and safety were assessed.

RESULTS

Of 369 patients enrolled, 220 underwent randomization and started receiving benralizumab or placebo. The two benralizumab dosing regimens significantly reduced the median final oral glucocorticoid doses from baseline by 75%, as compared with a reduction of 25% in the oral glucocorticoid doses in the placebo group (P<0.001 for both comparisons). The odds of a reduction in the oral glucocorticoid dose were more than 4 times as high with benralizumab as with placebo. Among the secondary outcomes, benralizumab administered every 4 weeks resulted in an annual exacerbation rate that was 55% lower than the rate with placebo (marginal rate, 0.83 vs. 1.83, P=0.003), and benralizumab administered every 8 weeks resulted in an annual exacerbation rate that was 70% lower than the rate with placebo (marginal rate, 0.54 vs. 1.83, P<0.001). At 28 weeks, there was no significant effect of either benralizumab regimen on the forced expiratory volume in 1 second (FEV1), as compared with placebo. The effects on various measures of asthma symptoms were mixed, with some showing significant changes in favor of benralizumab and others not showing significant changes. Frequencies of adverse events were similar between each benralizumab group and the placebo group.

CONCLUSIONS

Benralizumab showed significant, clinically relevant benefits, as compared with placebo, on oral glucocorticoid use and exacerbation rates. These effects occurred without a sustained effect on the FEV1. (Funded by AstraZeneca; ZONDA ClinicalTrials.gov number, NCT02075255.)

Reference: N Engl J Med 2017; 376:2448-2458June 22, 2017