#550 - Erratum, Smoking Cessation, Pediatric Obesity, It’s Halftime!
Take 3 – Practical Practice Pointers©
Mea Culpa – Watch the Dosing Information for Vitamin D!
Johns’ Comments: In my piece about vitamin D supplementation last week, I inadvertently wrote mcg (micrograms) instead of IU (international units) for the usual recommended supplementation doses. I’m usually very careful about that…because both IU and mcg are used routinely in drug references, but most clinical recommendations are written in IU. The recommendation sentence should have read: “For supplementation, the society recommends daily, low-dose vitamin D (400-800 IU/day)…“ For reference, 400 IU of vitamin D3 is 10 mcg.
My apologies, and thanks to the alert reader that questioned it. Please feel free send us a note if something we say doesn’t make sense; we’re always happy to clarify…or correct.
From the Literature
1) Very Brief Advice for Smoking Cessation
For years, the standard model for smoking cessation (as well as cessation of other addicting substances) has been SBIRT – Screening, Brief Intervention, and Referral to Treatment. Although this method was meant to standardize and somewhat streamline substance abuse counseling, primary care clinicians can rarely accomplish all the steps in clinical practice. The Brief Intervention part alone comprises models like the “Five As”: Ask, Advise, Assess, Assist, and Arrange follow up. When coupled with the necessary Screening activities and Referral for Treatment discussions, these are challenging to fit into practice. Very Brief Advice (VBA, models such as “AAR” - Ask, Advise, Refer or “ABC” - Ask about smoking, give Brief advice and offer Cessation therapy as needed) were invented to make these techniques more usable.
A multi-national research group conducted a systematic review of VBA’s effectiveness for smoking cessation compared to no advice/usual care. Studies were selected that were controlled trials of VBA (<3 minutes of intervention per patient) vs. control, and outcomes included continuous smoking cessation after 6 months (by self-report or biochemical confirmation). There was a comprehensive search performed and very specific selection criteria were applied. The studies were assessed for risk of bias using the Cochrane tool, and heterogeneity was assessed in a couple of ways.
Thirteen studies were found that met inclusion criteria. The studies were of overall moderate risk of bias, mostly due to issues of blinding, attrition bias, and outcome reporting. The crude relative risk (RR) of self-reported smoking cessation with VBA was 1.28 (95% confidence interval (CI) 1.10–1.49; NNT ~ 66). After non-pre-specified analysis that corrected for some publication bias, VBA still resulted in more cessation at 6 months: RR 1.17, 95% CI 1.07–1.27; NNT ~ 73. There were five studies that measured biochemically validated abstinence; the meta-analysis of these revealed a bigger relative risk of 1.53, but it was not statistically significant (95% CI 0.98–2.40; NNT ~ 256).
John’s Comments:
While neither the strength of evidence nor the results of VBA interventions are especially impressive, they may be worth trying if the full SBIRT is not practical. It’s certainly easier to remember. We need to keep studying brief interventions for behavioral change like this to incorporate into our busy primary care practices. VBA has been shown to work with alcohol overuse, so maybe we’ll get better evidence for it for smoking eventually.
Reference:
- Cheng CCW, He WJA, Gouda H, et al. Effectiveness of Very Brief Advice on Tobacco Cessation: A Systematic Review and Meta-Analysis. J GEN INTERN MED. Published online May 2, 2024. Link
From the USPSTF
2) Interventions for High BMI in Children and Adolescents
Approximately 20% of children and adolescents aged 2-19 in the US have a body mass index (BMI) at or above the 95th percentile for age and sex, based on Centers for Disease Control and Prevention (CDC) growth charts from 2000. Though the use of BMI has received criticism, its use is the currently accepted clinical standard measure of excess fat in the US, and childhood and adolescent weight status is usually obtained by calculating BMI. Traditionally, children and adolescents are categorized as having “obesity” when their BMI is at or above the 95th percentile on CDC growth charts.
The USPSTF recently updated its 2017 recommendation for screening for obesity in this age group. In the updated recommendation, the USPSTF used the general term “high BMI” when referring to youth with a body weight status ≥95th percentile for age and sex according to CDC standards. The Task Force acknowledges that BMI is an imperfect measure of adiposity and is not an equivalent measure of adiposity across all racial and ethnic populations. However, they note that most children with a BMI-for-age at or above the 95th percentile have high adiposity, while few children with a BMI-for-age below the 85th percentile have high adiposity.
The USPSTF now recommends that clinicians provide or refer children and adolescents 6 years or older with a high body mass index (≥95th percentile for age and sex) to comprehensive, intensive behavioral interventions. (B recommendation). They note that to achieve benefit, it is important that this group receive intensive (26 or more contact hours) behavioral interventions based on present data.
The data indicates that comprehensive, intensive behavioral interventions that include supervised physical activity sessions for up to 1 year result in weight loss in children and adolescents. Effective, high-intensity (≥26 contact hours) behavioral interventions result in greater weight loss than less intense interventions and result in some improvements in cardiometabolic risk factors. While there was variation, many of the studied interventions included sessions targeting both the parent and child (separately, together, or both); offered group sessions in addition to individual or single-family sessions; provided information about healthy eating, safe exercising, and reading food labels; and incorporated behavior change techniques such as problem solving, monitoring diet and physical activity behaviors, and goal setting. These types of interventions are often delivered by multidisciplinary teams, including clinicians, exercise physiologists or physical therapists, dietitians or diet assistants, psychologists or social workers, or other behavioral specialists.
The USPSTF recognizes the challenges that the families of children and adolescents encounter in accessing effective, intensive behavioral interventions for high BMI. Identifying high BMI and how to address it are important steps in helping children and adolescents and their families obtain the support they need. The USPSTF also understands that stigma associated with high BMI can be harmful to children and adolescents. However, there was no evidence that behavioral interventions resulted in additional stigma. Also, none of the trials found a decrease in self-esteem or body satisfaction, or an increase in disordered eating, associated with behavioral interventions.
The Task Force notes that while several medications demonstrated greater weight loss than placebo, the totality of the evidence was found to be inadequate. An important limitation of the pharmacotherapy studies was that there was only a single trial for each effective medication (ie, phentermine/topiramate, semaglutide, and liraglutide) that lasted longer than 2 months. The limited evidence on weight maintenance after pharmacotherapy discontinuation suggests that weight rebound starts soon after discontinuation, implying that long-term use will be needed to maintain weight loss. However, there is no evidence on the harms of long-term medication use. Therefore, the USPSTF encourages clinicians to promote behavioral interventions as the primary effective intervention for weight loss in children and adolescents.
Mark’s Comments:
Similar to the 2023 American Academy of Pediatrics (AAP) 2023 practice guideline for the evaluation and management of children and adolescents with obesity which was highlighted in the January 14, 2023 Take 3, the USPSTF emphasizes that active, comprehensive, and intensive intervention and not simply “watchful waiting” is the approach that will lead to more desirable outcomes for this population. This is certainly desirable given the potential long-term individual and population impacts of high BMI. This Algorithm from the American Academy of Pediatrics 2023 practice guideline, which generally is in alignment with the USPStF, provides a useful 1-page overview of the AAP recommendations.
References:
- USPSTF. Interventions for High Body Mass Index in Children and Adolescents: US Preventive Services Task Force Recommendation Statement. JAMA. Published online June 18, 2024. doi:10.1001/jama.2024.11146. Link
- Hampl SE, et al. Executive Summary: Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents with Obesity. Pediatrics. January 9, 2023; DOI: 10.1542/peds.2022-060640. Link
From PeerRxMed ( www.PeerRxMed.org )
3) It’s Halftime
“It’s halftime for 2024!” said July 1st
Part of the inspiration for the PeerRxMed process was the recognition that the work we do in healthcare will regularly create the conditions that can put us “off-course” and potentially “drain” us regarding any and all aspects of our personal and professional well-being. Under such circumstances, we risk becoming distanced from meaning, identity, priorities, perspective, and from each other. That is why it is essential to schedule regular time for recovery and recalibration and also why we need others in our lives who can help provide input, encouragement, and accountability .
A vital component of the PeerRx process is what I call PRx90, the quarterly “up to 90 minutes every 90 days” check-in with your PeerRx partner or other colleague intended to provide a deliberate space for and deeper reflection and connection. Here’s a reminder of that process.
When you schedule time to connect, here are some questions to consider for dialogue together:
- What would you say are your present top 2 personal and professional priorities and how are you incorporating them deliberately into your life?
- What have you learned about yourself over the past 3 months?
- What are your personal/professional goals over the next three months? What is one that will cause disappointment if you have not accomplished it when we meet again in 3 months?
- What are your dreams both personally and professionally? How are you taking action to move toward them?
- When’s your next vacation / adventure / break? What will you do that will be fun for you?
Taking time regularly for reflection, recovery, and recalibration is not selfish, but rather sanity and ultimately good stewardship of your life energy. Sadly, it is often neglected by those who are always “on the go” and/or perpetually “needed by others.” So don’t skip 2024 halftime! Schedule some personal time in the next 2 weeks for a “life check-up” to ensure you’re on target for living the life you want to be living using the questions above as a guide. That time should include writing down your answers to the questions above. In addition, schedule some face-to-face time (live or via video) to allow you and your PeerRx partner to provide mutual support and encouragement. It will help make for an even better “Second Half” for you as well as for all those people in your life who are impacted by you. That sounds like a wise investment to me!
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Mark and John
Carilion Clinic Department of Family and Community Medicine
Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.