兒科醫師提供的肥胖介入方法難以減少BMI


  【24drs.com】兒科實務指引建議,在第一線照護提供身體質量指數(BMI)監測與例行性體重管理諮詢,但是,一篇新的系統性回顧與統合分析顯示,這對於BMI的影響有限。
  
  明尼蘇達州羅徹斯特梅約診所精神科和心理科Leslie A. Sim博士等人,在9月12日的小兒科期刊發表他們的研究結果, 他們比較了以辦公室為基礎的體重管理介入方法,例如動機訪談以及改變生活型態行為之教育,以及任何對照介入,如一般照護、沒有介入、只有回饋意見等,對於2-18歲孩童與青少年之BMI的影響。
  
  研究者發現,相較於一般照護或對照治療,這些介入方式使BMI z分數獲得顯著但小量的減少(-0.04; 95%信賴區間-0.08至-0.01;P < .02),但是各研究之間無一致性(I 2 index = 0%);對身體滿意度無顯著影響(標準化平均值差異,0.00;95%信賴區間-0.21 至0.22;P = .98;I 2 index = 64.1%)。
  
  作者們寫道,為了釐清研究結果,對於BMI值位於第90百分位的10歲女孩,效果相當於在0-3年追蹤期間,介入組與對照與之間有1公斤的差異。
  
  他們指出,因為BMI z分數須減少0.5-0.6才會有健康效益,這些介入方式一般是無效的,也許資源可以得到更好的利用。
  
  他們表示,除了效果有限,對孩子提供體重諮商可能有潛在傷害。
  
  研究者解釋,以前的證據認為,醫師們有關減重的談話對於增加體重相關的汙名化、隨之暴飲暴食和體重增加、以及飲食失調的風險較高等,可能有意想不到的後果。
  
  
  他們表示,統合分析結果強調,須修改實務指引以及提供新方法。
  
  在編輯評論中,北卡羅來納杜克大學小兒科的Sarah C. Armstrong醫師以及杜克臨床研究中心的Asheley Cockrell Skinner博士同意,這些研究結果將促使醫師、研究人員和政策制定者評估介入措施。
  
  他們寫道,缺乏效果是特別顯著的,因為他們只有採用已發表的試驗;有更多無效的試驗很可能從未被提出報告。
  
  不過,他們也質疑,BMI是否是篩檢成功與否的正確方法。
  
  Armstrong醫師與Skinner博士寫道,無法減少BMI不應與沒有採取更健康的行為相提並論。
  
  他們解釋,就像戒菸可以減少慢性阻塞性肺部疾病與肺癌的死亡率,改善飲食與改變行為可以改善血糖值、脂質與血壓。
  
  所以,如果在第一線照護診療時不討論BMI,醫師們會錯過與人們討論促成改變之動機的機會,而且,如果不提及對體重的擔憂,人們可能會留下一切都很好的印象。
  
  另外,如果減少BMI是成功與否的唯一測量方法,家人們不會稱讚他們已經達到的其他建康效益。
  
  他們表示,研究者強調潛在傷害是對的,但是,他們也指出,以前的研究顯示,父母們希望在可信任的醫療機構對於體重方面有非主觀的討論,而這些會談不會增加不安全節食的風險、且會增加改變行為的渴望。
  
  他們寫道,我們相信,要改變這領域,不只將需要方法嚴謹的隨機對照試驗,還得使用新的研究設計,如實用試驗,以確認肥胖照護的效果,並且使用聯網數據系統,以便更佳地理解兒童肥胖之發展和軌跡。
  
  資料來源: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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