Obesity in Children and Adolescents (Screening)

Evidence Statement: Screening for Childhood and Adolescent Obesity Benefit Plan Language Other Information and Resources Author(s)

References


Updated 6/7/11

Evidence Statement: Screening for Childhood and Adolescent Obesity

Clinical Preventive Service Recommendations

U.S. Preventive Services Task Force Recommendation
The USPSTF recommends that clinicians screen children aged 6 years and older for obesity and offer them or refer them to comprehensive, intensive behavioral interventions to promote improvement in weight status.1

Evidence Rating: B (Recommended/Moderate Certainty)
The USPSTF concludes that there is moderate certainty that the net benefit is moderate for screening for obesity in children aged 6 years and older and offering or referring children to moderate- to high-intensity interventions to improve weight status.1


Condition / Disease Specific Information

Epidemiology of Condition/Disease
Since the 1970s the prevalence of obesity has increased in children and adolescents.2 Between 1976-1980 and 2007-2008, obesity increased:
  • From 5 to 10.4% in pre-school aged (2 - 5 years) children;
  • From 6.5 to 19.6% in children 6-11 years; and,
  • From 5 to 18.1% in adolescents (12 - 19 years).


Results from the 2007-2008 National Health and Nutrition Examination Survey (NHANES) indicated that 16.9% of children and adolescents ages 2-19 years were obese.2,3 This corresponds to approximately 12.5 million children and adolescents who are struggling with unhealthy amounts of excess weight.4

Obesity has serious health consequences for children and adolescents. 5-9 Obesity in children and adolescents increases their risk of:
  • Type 2 diabetes mellitus;
  • Asthma;
  • Cardiovascular risk factors;
  • Mental health conditions such as depression; and,
  • Low self-esteem.

The complications of being obese are particularly severe for children due to the years of life they are at risk of losing as a result of early-onset chronic diseases, such as diabetes10,11 and cardiovascular disease.11Unless they adopt and maintain healthier patterns of eating and physical activity, children and adolescents who are obese may become adults with weight-related co-morbidities.

The most common method used to screen children and adolescents for obesity is Body Mass Index (BMI) which measures weight in relation to height.12 This makes BMI an easy measure to calculate and an accepted screening tool. As a screening assessment of body fatness, BMI in children and adolescents must also account for age- and sex-related changes.
Condition/Disease Risk Factors
Several factors increase the risk of child and adolescent obesity.13-15 These factors include:
  • Sedentary behavior;
  • Over consumption of sugar-sweetened beverages; and
  • Over consumption of high-calorie, energy-dense foods.

Environments that do not promote healthy and active lifestyles (i.e., lack of safe walking areas, parks and recreational facilities; lack of healthy food options) may contribute to obesity by contributing to poor diet or physical inactivity.16

The Value of Prevention

Economic Burden of Condition/Disease
As mentioned above, obesity is associated with costly health conditions in children and adolescents, and contributes significantly to medical costs in the United States. A recent analysis of the Medical Expenditure Panel Survey determined that compared to children who had a normal/low BMI, children and adolescents who were obese during both years of the 2-year course of the study had increased expenditures of $194 in outpatient visits, $114 in prescription drugs and $12 in emergency room visits.17 The total annual direct medical expenditures associated with obesity in children and adolescents across the nation was estimated at $1.8 billion.

Workplace Burden of Condition/Disease
Children and adolescents are responsible for 14.7% of a typical large employer's health care costs.18,19 Compared to non-obese children, obese children are three times more likely to be hospitalized and have greater use of physician services.20

Furthermore, compared to children with a normal BMI, obese children are more likely to miss more days of school.21 For parents and caregivers, school absences can result in work tardiness or absence and 3early departures from work.

Economic Benefit of Preventive Intervention
Behavioral interventions, such as nutrition education, and physical activity counseling can be effective interventions for obesity prevention and have the potential to reduce the costs of obesity-related illnesses.
Estimated Cost of Screening and/or Counseling
The cost of BMI screening is negligible when height and weight measurements are already recorded as part of a child or adolescent's routine physical exam.

In 2007, the median private-sector cost of any health and behavior assessment or intervention claims used in child obesity was $87.00.22 Approximately 95% of all paid claims fell within the range of $22.00 to $262.00.22

Cost-Effectiveness and/or Cost-Benefit Analysis of Preventive Intervention
There is limited information on the cost effectiveness of obesity screening, counseling and referrals in clinical settings. This is especially true for moderate- to high-intensity intervention programs (defined as >26 hours of contact or intervention time in a 6-month period). However, a cost-effectiveness analysis model based on the Live, Eat And Play (LEAP) trial indicated that screening and behavioral counseling in the clinical setting were cost-effective compared to no intervention.23



Preventive Intervention Information

Preventive Intervention: Purpose of Screening and Counseling
Screening for obesity allows clinicians to identify patients at risk and begin appropriate intervention before serious weight-related complications occur. Once identified, clinicians can refer patients to comprehensive moderate- to high-intensity programs that include dietary, physical activity, and behavioral counseling components.

Benefits and Risks of Intervention
Benefits:
The US Preventive Services Task Force found evidence that multi-component, moderate- to high-intensity behavioral interventions for obese children and adolescents aged 6 years and older effectively yield improvements in weight status in the short-term (12 months or less).1

Because obesity is a modifiable major risk factor for several serious conditions, screening for obesity and treating it successfully may produce significant health benefits for children and adolescents.

Risks:
There is adequate evidence that the harms of behavioral interventions are minimal.1 In a review of evidence, the US Preventive Service Task Force found little evidence of adverse effects on growth, eating disorders, or mental health and little risk of exercise-induced injuries related to weight-management behavioral interventions.
Initiation, Cessation, and Interval
Screening
No evidence was found regarding appropriate intervals for screening.1 However, height and weight, from which BMI is calculated, are routinely measured during regular health maintenance visits.

Treatment
Moderate intensity programs involve 26-75 hours, and high intensity involve >75 hours of contact with the child and/or the family over a 6-month period.

Intervention Process
The preferred method of screening for obesity is to measure their body-mass index (BMI).12 The USPSTF found that effective comprehensive weight-management programs incorporated counseling and other interventions that targeted diet and physical activity. Interventions also included behavioral management techniques to assist in behavior change.1 Interventions that focused on younger children incorporated parental involvement as a component.1

Screening
BMI is calculated as weight in kilograms divided by height in meters-squared. 13 For children and adolescents 2-19 years, the BMI value is plotted on the Centers for Disease Control and Prevention (CDC) growth charts to determine the corresponding BMI percentile, based on age and sex. Overweight and obesity classifications for children and adolescents are age- and sex-specific since children's body composition varies by sex and age.24

BMI is a widely accepted screening tool because it is relatively easy to obtain the height and weight measurements needed to calculate BMI, measurements are non-invasive and BMI correlates with body fatness.12 BMI is feasible, reliable and tracks with adult obesity measures. Furthermore, the sensitivity of BMI for detecting high adiposity increases with increasing BMI percentiles.7
Classification of Body Mass Index (BMI) for Children25
Classification Definition
Healthy Weight BMI between the 5th and 84th percentile for children of the same age and sex
Overweight BMI at or above the 85th percentile and lower than the 95th percentile for children of the same age and sex.
Obese BMI at or above the 95th percentile for children of the same age and sex.

While BMI is an accepted screening tool for the initial assessment of body fatness in children and adolescents, it is not a diagnostic measure because BMI is not a direct measure of body fatness.3
Counseling and Treatment Information
Comprehensive interventions for obesity include:
  1. counseling for weight loss or healthy diet;
  2. counseling for physical activity; and,
  3. instruction and support for the use of behavioral management - such as self-monitoring, stimulus control, eating management, contingency management, and cognitive behavioral practices - to maintain dietary and exercise modifications.1


Moderate intensity programs involve 26-75 hours, and high intensity involve >75 hours of contact with the child and/or the family over a 6-month period.1 Interventions generally take place in referral settings (such as a pediatric obesity referral clinics), and the results can only be generalized to children who follow through on treatment.

The USPSTF review indicates that these programs are associated with improved weight status, which is defined as an absolute and/or relative decrease in the child's BMI 12 months after the beginning of the intervention.1

Other Important Information

In 2007, an expert committee convened by the American Medical Association (AMA) in collaboration with Centers for Disease Control and Prevention (CDC) and Health Research Services Administration (HRSA), updated recommendations on how clinicians should approach the prevention, assessment, and treatment of childhood obesity.26 The panel advised that a clinician's assessment should include a BMI calculation as well as medical and behavioral risks for obesity.

For obese patients, the panel proposed dividing treatment into steps that include:
  • Counseling;
  • Providing a structured weight management plan; and,
  • Using a comprehensive intervention delivered by expert multidisciplinary teams.

The American Academy of Pediatrics endorsed the 2007 expert committee recommendations and has also recommended the annual plotting of BMI for all patients aged 2 years and older.26

Strength of Evidence for the Clinical Preventive Service

The level of evidence supporting the recommendations contained in this chapter is described below.
Evidence-Based Research:
U.S. Preventive Services Task Force (USPSTF)
Strength of evidence: B (Recommended/Moderate Certainty)
  • The USPSTF recommends that clinicians screen children aged 6 years and older for obesity and offer them or refer them to comprehensive, intensive behavioral interventions to promote improvement in weight status.1

Summary Plan Description Language: Obesity (Counseling)

Covered Counseling
Intensive counseling (2 or more person-to-person individual or group sessions per month, for at least 3 months) is a covered benefit for beneficiaries aged 18 and older who meet criteria for obesity (BMI > 30).

Initiation, Cessation, and Interval
Six (6) counseling sessions are covered per calendar year. Additional sessions are covered, if medically indicated.

Summary Plan Description Language: Obesity (Treatment)

Covered Treatment Medications
All FDA-approved medications for the treatment of obesity or weight loss are are covered. Coverage is reserved for beneficiaries with a BMI higher than 30 and beneficiaries with a BMI of 27 to 29 who also have at least one additional major risk factor for cardiovascular disease. Coverage for medication is contingent on physician monitoring and participation in an individual or group counseling program.

Procedures
Surgical treatment procedures are covered. Coverage is reserved for beneficiaries aged 18 and older with class III obesity (BMI exceeding 40) and beneficiaries with class II obesity (BMI of 35 or higher) who also have at least one obesity-related illness. All obesity-related surgical procedures are subject to pre-authorization requirements.

Initiation, Cessation, and Interval
The duration of treatment is determined by the type of medication used and its dosage. Coverage is provided for medications and surgery, as prescribed by a clinician.



CPT Codes

CPT Codes
96150 Health and behavior assessment (eg, health-focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionnaires), each 15 minutes face-to-face with the patient; initial assessment
96151 Health and behavior assessment (eg, health-focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionnaires), each 15 minutes face-to-face with the patient; re-assessment
96152 Health and behavior intervention, each 15 minutes, face-to-face; individual
96153 Health and behavior intervention, each 15 minutes, face-to-face; group (2 or more patients)
96154 Health and behavior intervention, each 15 minutes, face-to-face; family (with patient present)
96155 Health and behavior intervention, each 15 minutes, face-to-face; family (without patient present)


Authored by:

Kraczkowsy K, Belay B. Child Obesity - Screening. Available online at: [INSERT LINK]



References

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