儿科医师提供的肥胖介入方法难以减少BMI


  【24drs.com】儿科实务指引建议,在第一线照护提供身体质量指数(BMI)监测与例行性体重管理咨询,但是,一篇新的系统性回顾与统合分析显示,这对于BMI的影响有限。
  
  明尼苏达州罗彻斯特梅约诊所精神科和心理科Leslie A. Sim博士等人,在9月12日的小儿科期刊发表他们的研究结果, 他们比较了以办公室为基础的体重管理介入方法,例如动机访谈以及改变生活型态行为之教育,以及任何对照介入,如一般照护、没有介入、只有回馈意见等,对于2-18岁孩童与青少年之BMI的影响。
  
  研究者发现,相较于一般照护或对照治疗,这些介入方式使BMI z分数获得显著但小量的减少(-0.04; 95%信赖区间-0.08至-0.01;P < .02),但是各研究之间无一致性(I 2 index = 0%);对身体满意度无显著影响(标准化平均值差异,0.00;95%信赖区间-0.21 至0.22;P = .98;I 2 index = 64.1%)。
  
  作者们写道,为了厘清研究结果,对于BMI值位于第90百分位的10岁女孩,效果相当于在0-3年追踪期间,介入组与对照与之间有1公斤的差异。
  
  他们指出,因为BMI z分数须减少0.5-0.6才会有健康效益,这些介入方式一般是无效的,也许资源可以得到更好的利用。
  
  他们表示,除了效果有限,对孩子提供体重谘商可能有潜在伤害。
  
  研究者解释,以前的证据认为,医师们有关减重的谈话对于增加体重相关的污名化、随之暴饮暴食和体重增加、以及饮食失调的风险较高等,可能有意想不到的后果。
  
  
  他们表示,统合分析结果强调,须修改实务指引以及提供新方法。
  
  在编辑评论中,北卡罗来纳杜克大学小儿科的Sarah C. Armstrong医师以及杜克临床研究中心的Asheley Cockrell Skinner博士同意,这些研究结果将促使医师、研究人员和政策制定者评估介入措施。
  
  他们写道,缺乏效果是特别显著的,因为他们只有采用已发表的试验;有更多无效的试验很可能从未被提出报告。
  
  不过,他们也质疑,BMI是否是筛检成功与否的正确方法。
  
  Armstrong医师与Skinner博士写道,无法减少BMI不应与没有采取更健康的行为相提并论。
  
  他们解释,就像戒菸可以减少慢性阻塞性肺部疾病与肺癌的死亡率,改善饮食与改变行为可以改善血糖值、脂质与血压。
  
  所以,如果在第一线照护诊疗时不讨论BMI,医师们会错过与人们讨论促成改变之动机的机会,而且,如果不提及对体重的担忧,人们可能会留下一切都很好的印象。
  
  另外,如果减少BMI是成功与否的唯一测量方法,家人们不会称赞他们已经达到的其它建康效益。
  
  他们表示,研究者强调潜在伤害是对的,但是,他们也指出,以前的研究显示,父母们希望在可信任的医疗机构对于体重方面有非主观的讨论,而这些会谈不会增加不安全节食的风险、且会增加改变行为的渴望。
  
  他们写道,我们相信,要改变这领域,不只将需要方法严谨的随机对照试验,还得使用新的研究设计,如实用试验,以确认肥胖照护的效果,并且使用联网数据系统,以便更佳地理解儿童肥胖之发展和轨迹。
  
  资料来源:http://www.24drs.com/
  
  Native link:Obesity Interventions by Pediatricians Barely Cut BMI

Obesity Interventions by Pediatricians Barely Cut BMI

By Marcia Frellick
Medscape Medical News

Pediatric practice guidelines recommend body mass index (BMI) surveillance and routine weight management counseling in the primary care setting, but a new systematic review and meta-analysis shows this has little effect on BMI.

Leslie A. Sim, PhD, from the Department of Psychiatry and the Department of Psychology at the Mayo Clinic in Rochester, Minnesota, and colleagues published their findings online September 12 in Pediatrics. They compared office-based interventions for weight management, such as motivational interviewing and education on changing lifestyle behaviors, with any control intervention, such as usual care, no intervention, or feedback only, on BMI in children and adolescents aged 2 to 18 years.

The researchers found that compared with usual care or control treatment, the interventions resulted in a significant but small reduction in BMI z score (?0.04; 95% confidence interval, ?0.08 to ?0.01; P < .02), with no inconsistency across studies (I 2 index = 0%); and a nonsignificant effect on body satisfaction (standardized mean difference, 0.00; 95% confidence interval, ?0.21 to 0.22; P = .98; I 2 index = 64.1%).

"To put the finding in context, for a 10-year-old girl with a BMI at the 90th percentile, the effect is equivalent to a difference between the intervention and control groups of 1 kg over a 0- to 3-year follow-up period," the authors write.

They note that because a BMI z score reduction of 0.5 to 0.6 is needed to show health benefit, the interventions are "generally ineffective," and perhaps resources could be better used.

In addition to having little effect, they say, counseling kids about weight could have potential harms.

Previous evidence suggests that physicians' conversations about weight loss may have unintended consequences of adding weight-related stigma, consequent binge eating and weight gain, and higher risk for eating disorders, the researchers explain.

They say the results of the meta-analysis highlight the need for revised practice guidelines and new approaches.

Is BMI The Right Measure of Success?

In an accompanying editorial, Sarah C. Armstrong, MD, from the Department of Pediatrics, and Asheley Cockrell Skinner, PhD, from the Duke Clinical Research Institute, both at Duke University in Durham, North Carolina, agree the findings should compel clinicians, researchers, and policy makers to reevaluate interventions.

"This lack of effect is particularly striking given their use of only published trials; many more ineffective trials were probably never reported," they write.

However, they also question whether BMI is the right measure of screening success.

"Failing to reduce BMI should not be equated with failing to adopt healthier behaviors," Dr Armstrong and Dr Skinner write.

Just as quitting smoking leads to reduced morbidity from chronic obstructive pulmonary disease and lung cancer, improving diet and changing behaviors can lead to improved glucose levels, lipid profiles, and blood pressure, they explain.

So by not talking about BMI in a primary care visit, physicians will miss the chance to talk with a family motivated to make changes. Also, by not mentioning concerns about weight, the family may be left with the impression that everything is fine.

In addition, if reduction in BMI is the only measure of success, families will not be praised for other health gains they may have achieved.

They say the researchers are right to highlight potential harms, but they also note that previous studies have shown parents want nonjudgmental conversations about weight conducted in a trusted medical home, and that those talks have not increased risk for unsafe dieting and have increased desire to change behaviors.

"We believe moving the field will require not only 'methodologically rigorous' randomized controlled trials but the use of innovative designs, such as pragmatic trials, to determine the effectiveness of obesity care and the use of networked data systems to better understand the development and trajectories of obesity in children," they write.

The authors and editorialists have disclosed no relevant financial relationships.

Pediatrics. Published online September 12, 2016.

    
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