Inequity reigns if behavioral interventions cannot be feasibly implemented, experts argue

U.S. Preventive Services Task Force (USPSTF) recommendations for obesity screening among children and adolescents cannot work effectively without proper resources for behavioral interventions, and failure to support these recommendations runs the risk of widening health inequities, researchers argued.

The USPSTF is an independent panel of experts designed to provide “unbiased, evidence-based recommendations to primary care providers regarding prevention-oriented services they should offer to patients showing no signs or symptoms of disease,” Hunter Jackson Smith, MD, MPH, MBE, of the Department of Preventive Medicine and Biostatistics at Uniformed Services University in Bethesda, Maryland, and colleagues explained in a Special Article published in Pediatrics.

However, while the USPSTF is capable of reviewing evidence and issuing recommendations based on the net benefit of a given service, the Task Force is not equipped to facilitate implementation of those recommendations, relying instead on stakeholders to “ensure the ethical application of such guidelines across diverse populations.”

The problem, Smith and colleagues argued, is that without the necessary support required to make behavioral interventions feasible, challenges in equity and access to care may leave some patients out in the cold—an outcome which, in the case of childhood obesity, can have deadly consequences.

“By not having screening and preventive intervention modalities for childhood obesity accessible equitably across populations, disparities are created and exacerbated between groups,” they wrote. “Obesity can incur a terrible toll on those in whom it afflicts, ranging from impaired mental health to restricted mobility to organ failure and more. These comorbid and associated conditions can then limit a person’s ability to fully pursue their goals unencumbered. If the American Dream is one in which individuals of any socioeconomic stratum or geographic background have the potential to successfully pursue their goals, then we are betraying this dream by leaving the inequities of childhood obesity unaddressed. This point becomes particularly pronounced after the realization that we have USPSTF-recommended (i.e., evidence-based and effective) screening and preventive interventions for this disease, but that these services remain inaccessible or limited for many of the populations who need it most.”

The article by Smith and colleagues “should be a national call to action,” Alex H. Krist, MD, MPH, of the Inova Health System in Fairfax, Virginia, and Virginia Commonwealth University in Richmond, and colleagues wrote in a commentary accompanying the study.

“Obesity is a major driver of poor health,” they argued. “Intensive behavioral interventions can change children’s weight status, fundamentally improving their trajectory for health and well-being. Clinicians need to develop collaborative relationships with local programs. Health systems and communities need to create and sustain accessible programs to help children and families in need. Employers, payers, and policymakers need to honor the intent of the Affordable Care Act and provide first-dollar coverage for programs. Researchers need to generate evidence to understand what intervention components are necessary and how to make more feasible interventions and strategies to promote equity. Public health is needed to create communities and environments that support healthy lifestyles and make healthy weight more accessible for all to obtain. Concerted efforts are required from all in our quest to accomplish better care for our children.”

Tackling Real-World Inequities

In their analysis, Smith and colleagues presented the case of David, a 10-year-old boy from a rural town in Louisiana whose BMI was >95th percentile, “a finding consistent with a diagnosis of obesity,” they explained.

David’s pediatrician recommended that he receive intensive behavioral counseling to manage his obesity—however, the nearest centers providing those services was over 75 miles away, which made travelling to seek care unfeasible for the family; thus, David instead received at-home diet and exercise materials.

Smith and colleagues argued that David’s story raises a number of questions regarding the ethical responsibilities of the state to the well-being of children, whether health care is a right, and what such a right to health care includes.

“If we agree that the concept of prevention is valuable; that USPSTF recommendations are strong, well-researched, and effective and ought to continue without recognition of cost; and that health equity is important, then efforts ought to be put forth to ensure that all children have access to these intervention modalities, and particularly for children in higher prevalence and higher risk groups,” they wrote.

So, how can these gaps be filled? Smith and colleagues briefly discussed several potential methods:

  • Better incentivizing the provision of intensive behavioral counseling for obesity in children: financial incentives for medical systems could lead to the creation of additional facilities and intensive services geared towards addressing childhood obesity; however, if reimbursement for quality performance metrics are based on evidence based recommendations, the authors argued that resource-poor areas may have trouble reaching those metrics and might not be able to obtain these financial incentives, which could potentially widen the equity gap.
  • Expanding clinical services so that physicians in low-resource areas are trained to provide the intensive behavioral counseling for obesity in children: This option carries challenges of its own, they noted, “particularly in areas where primary care doctors are scarce and where the primary care shortage may be growing.” Such areas may not have the health care staff necessary to expand to meet this need.
  • Expanding and strengthening the collaborative network of stakeholders, including public health, clinicians, social justice organizations, and communities: Smith and colleagues wrote that these groups should evaluate USPSTF recommendations for equity, cost, and access concerns upon their release so that resources can be aligned to support low-resource areas.
  • Recognizing that recommendations and interventions remain available at all levels of care for childhood obesity: The authors pointed to groups such as the Community Preventive Services Task Force, which is designed to develop evidence-based guidance regarding community-based preventive interventions and services. “Some clinics or communities may not have the resources to deliver comprehensive, intensive, evidence-based interventions,” they wrote. “However, they may be able to provide the diagnosis in clinic, bring attention to the issue, and subsequently engage in alternative options that are less resource intensive, recognizing possible gaps in the evidence for their effectiveness.”

Addressing Evidence Gaps

Another key consideration, Smith and colleagues argued, is addressing evidence gaps for vulnerable and disadvantaged populations.

While USPSTF looks for the best available evidence to support clinical preventive services, the data are often lacking for diverse and vulnerable groups, and services are not equitably available for Black, Indigenous, and Hispanic/Latinx individuals.

Krist and colleagues noted that this lack of data does not stem from USPSTF itself, and indeed “the USPSTF has sought to address health equity in its recommendations. Evidence reviews start with identifying populations with a higher prevalence or who experience greater morbidity or mortality from the condition and then applying rigorous methods to discern causal factors for inequities, which can include systemic racism and implementation barriers.”

The problem is that for many populations, the necessary volume of research for tailoring interventions to these groups does not exist.

“As such, an upstream method to implement childhood obesity interventions ethically and equitably is to first perform the research that studies the effectiveness of screening and interventions in diverse and vulnerable populations,” Smith and colleagues wrote. “A key component to this might include an emphasis on comparative effectiveness studies that rank clinical and community preventive services for childhood obesity with a special focus on vulnerable and resource-constrained populations.”

While the evidence gaps raised by the USPSTF are used by the National Institutes of Health to direct funding streams for future research, the authors argued that “further innovative solutions, integrated partnerships, and long-term funding commitments will likely be required to confront this complex issue… there may be a larger ethical need for funding to build and maintain the capacity to address childhood obesity in low-resource areas as part of a national strategy to eliminate disparities. Ultimately, it is essential to recognize that effectively addressing childhood obesity at a population level and achieving health equity must also focus on preventing obesity through improving social determinants of health and other systemic causes of obesity.”

  1. Researchers argued that more efforts, including increased incentives or expansion of clinical services in low-resource areas, should be taken to facilitate USPSTF recommendations of intensive behavioral interventions for obesity among children and adolescents.

  2. Performing research that studies the effectiveness of pediatric obesity screening and interventions in diverse and vulnerable populations is necessary to address inequities in the implementation of USPSTF-recommended obesity interventions.

John McKenna, Associate Editor, BreakingMED™

The article authors had no relevant relationships to disclose.

Commentary coauthors Davidson and Silverstein are members of the USPSTF; Krist had no relevant relationships to disclose.

Cat ID: 252

Topic ID: 85,252,730,795,252,518,917