Written by Debbie Koenig
Jan. 13, 2023 -- The American Academy of Pediatrics last week issued their first new guidelines in 15 years for evaluating and treating kids and adolescents with overweight or obesity.
If you only saw the headlines, you might think that when a youngster is a few pounds overweight, their pediatrician will prescribe a weight loss drug or bariatric surgery. The reality is much less alarming. The guidelines take a deep dive into evidence-based treatments at various levels.
“It's a misunderstanding, it's being sensationalized,” says Lori Fishman, PsyD, a child psychologist who specializes in pediatric weight management. “There's so much more to the process. It'll be a small percentage of kids who'll even qualify for these treatments.”
Treating the Whole Child
Before writing the guidelines, the AAP's Subcommittee on Obesity spent years analyzing and synthesizing information from nearly 400 studies.
“We now have more information than ever that supports that obesity is a chronic, complex disease that requires a whole-child approach,” says Sarah Hampl, MD, one of two lead authors of the guidelines. “And many kids will not outgrow it, so it's important to identify children with obesity early and offer them evidence-based treatments.”
In the new guidelines, treatment of overweight and obesity doesn't mean putting a kid on a diet and expecting their parents to manage it. Instead, multi-pronged approaches might include nutrition support, physical activity specialists, behavioral therapy, medications for adolescents 12 and up, and surgery for teenagers with severe obesity.
Before starting any of these evidence-based treatments, the guidelines remind pediatricians to consider each child's individual circumstances -- their living situation, their access to healthy food, and more.
“As pediatricians, we ought to be especially mindful of the influences that child and family are surrounded by,” Hampl says. “We should help guide them, whether it's to local resources for healthy food or support for a child who's being bullied.”
Because obesity is often stigmatized, the pediatricians' group also included guidance for pediatricians to help them examine their own biases. It calls on them to acknowledge the myriad genetic and environmental factors that contribute to obesity and treat children and their parents with respect and sensitivity.
The Rise of Childhood Obesity
For kids 2-18, obesity is defined as having a BMI at or above the 95th percentile for a child's age and sex. Rates of pediatric obesity have more than tripled since the 1960s, from 5% to nearly 20%. Just last month, the CDC released updated growth charts to take into account how many more children and adolescents now have severe obesity, well beyond the 95th percentile. By 2018, more than 4.5 million kids qualified, but the old charts didn't go high enough.
If these trends continue, researchers estimate that 57% of children aged 2 to 19 will have obesity by the time they hit 35. And the pandemic has only made things worse.
“It's about much more than what we eat and drink or how physically active we are,” Hampl says. Risk factors for obesity include genetics, socio-economics, race and ethnicity, government policies, a child's environment, neighborhood, and school, and even their exposure to unhealthy food marketing. Because each child is so different, these factors combine in unique ways.
You can see an example of the variability in Jill's family. She's a New Jersey mom with two teenage sons. For privacy reasons, we're using only her first name.
“I have two children who I raised the same way, who were offered the same foods, and yet one weighs 80 pounds more than the other,” she says. “My 16-year-old is happy to choose fruit over a cookie. He's able to stop, to not eat another bite. The 14-year-old will eat cookies until they're gone.”
No More Watch and Wait
The last set of guidelines, from 2007, called for pediatricians to monitor kids with obesity via “watchful waiting.” It would give children a chance to outgrow their excess pounds before being treated. Research conducted since then shows that's not effective.
“The risk of watching and waiting, in my experience, is that a 10-pound-overweight child a year later might be 30 pounds overweight,” says Fishman. “That's a lot harder to tackle.”
In the new guidelines, the AAP stresses the urgency of treating children with overweight and obesity as soon as it's diagnosed. Instead of hoping a growth spurt might take care of the problem, pediatricians should move quickly, “at the highest level of intensity appropriate for and available to the child.”
By guiding children and their families to adopt healthier habits early, it may help to reduce some of the weight-related health issues that have also increased in the last few decades. Just within the 21st century, diabetes rates for children and teenagers have skyrocketed -- between 2001 and 2017, the number of kids with type 2 went up an astonishing 95%.
“Now we understand the consequences of untreated obesity, especially severe obesity,” says Mary Ellen Vajravelu, MD, a doctor-scientist at the Center for Pediatric Research in Obesity and Metabolism in Pittsburgh. “That includes type 2 diabetes, fatty liver disease, high blood pressure, high cholesterol. It's important to treat obesity in childhood to avoid the complications we're seeing in young adults.”
Also important: Reversing the trend while a child is young can help them avoid the emotional impact of growing up with obesity.
“I saw the recommendations and thought, 'How different would my life have been for the past 35 years if they had treated my obesity when I was a child?” says Heather, the mother of a 10-year-old in Florida. She's been limiting herself since childhood, for instance by avoiding activities where her size might prove embarrassing. “For kids who are struggling, I think it'll be life-changing.”
What the Guidelines Really Say
In a world where fat-shaming is rampant, parents often want to protect their children by encouraging them to lose weight -- but parental pressure adds another layer of bad feelings. The AAP advises against putting a child on a diet or restricting their access to food without professional help. Guidelines recommend that pediatricians:
Treat obesity as a chronic disease. That calls for long-term care strategies and ongoing monitoring.
Implement a model known as the “medical home.” It takes treatment beyond the exam room to shape behavior and lifestyle changes. Pediatricians should build partnerships with families in their care and serve as a care coordinator, working with a team that may include obesity treatment specialists, dietitians, psychologists, nurses, exercise specialists, and social workers.
Use a patient-centered counseling style called motivational interviewing. Rather than a doctor prescribing changes for a child's family to figure out, the process guides families to identify which behaviors to adjust based on their own priorities and goals -- that might mean cutting back on sugary drinks or walking together after dinner. Research has shown it takes less than 5 hours of motivational interviewing with a pediatrician or dietitian to help bring down BMI.
Opt for an approach called intensive health behavior and lifestyle treatment (IHBLT) whenever feasible. As the name suggests, it's an intense treatment that calls for at least 26 hours of face-to-face, family counseling on nutrition and exercise over a period of 3 to 12 months. More sessions produce larger reductions in BMI, with 52 hours or more over the same duration having the greatest impact. Unfortunately this treatment program isn't available everywhere, and for many families the time and financial demands put it out of reach.
Offer approved weight loss drugs to adolescents 12 years and older who have obesity. Medication should always be used together with nutrition and exercise therapies.
Refer adolescents 13 and up with severe obesity for possible weight loss surgery. That referral should be to a surgical center with experience in working with adolescents and their families, where the teen would undergo a thorough screening process.
Medication and Surgery
Those last two recommendations have garnered most of the headlines, and it's understandable. Medicating a child -- or performing an operation that would permanently change their body -- might seem extreme. But the research shows that for children with obesity and severe obesity, these treatments work.
“This isn't for a kid who's a little overweight,” says Fishman. “It's obesity that's limiting this child's ability to function. When we face something this disabling, we want to attack it from every direction we can.”
Right now, only a handful of medications are approved to treat obesity in adolescents. Some are taken orally, while others, like the recently approved Wegovy, are injected.
Jill, the New Jersey mom, is using Wegovy herself.
“The fact that I've had success with it makes me more comfortable about approaching it as an option for my son,” she says. “And ultimately, it's his choice. If he wants to see if he can just do things differently first, we'll try that. A nutritionist's guidance will be part of this for him regardless, so he can understand what's involved. It's not like he'll get the shot and all of a sudden magic happens.”
Losing weight with medication can help remove some of the shame that often comes with obesity. Heather, the Florida mom, is also using an injectable drug.
“It's all the morality stuff like, if you had more self-control, if you worked harder and really tried, if you just made the choice,” she says. “This pulls all the morality out of it. Obesity is a medical condition. It's so clear. In the same way I take thyroxin because my thyroid doesn't work well, this makes my insulin receptors work properly.”
For kids 13 and older with severe obesity -- a BMI over 35, or 120% of the 95th percentile for age and sex -- metabolic or bariatric surgery may be recommended. Of course, surgery is much more invasive than medication, with a greater risk of complications. The guidelines acknowledge this and stress the need for thorough screening before proceeding.
“The pediatrician would refer a child for evaluation. They wouldn't say, 'You definitely need to have surgery,'” Hampl says. “They'd say, 'As your pediatrician, I feel that you would benefit from a comprehensive evaluation at a pediatric bariatric surgical center.' These types of centers do a very thorough pre-op evaluation over at least 6 months, and then careful monitoring is done for years afterward.”
Weight loss surgery for adolescents does have certain drawbacks. Any surgery has the risk of complications, and some surgical patients do gain back a significant amount of weight. Some research suggests that adolescents who have the surgery are more likely to have alcohol problems later in life.
Even with those risks, for some teens surgery may prove life-saving.
“We know much more about the complications of obesity in adults, we know those are devastating,” says Hampl. “If we can prevent heart attacks, stroke, sleep apnea, diabetes, and other really serious medical complications, that in itself is a huge benefit to the person's health.”
The Question of Equity
The guidelines point out that obesity has inequities baked into the condition. Risk factors increase depending on your economic status and your race. Access to treatment is lopsided. Some of the most effective treatments, like intensive health behavior and lifestyle treatment, aren't available everywhere. Providers may not be in-network or even accept insurance.
If the family of a child with overweight can't access effective programs to help them build healthy habits, the child's odds for developing obesity grow. As they get older and their BMI reaches the level of obesity or severe obesity, treatments like medication and surgery become an option. But they're even more costly, which leaves many families with no help at all.
That's why the guidelines also include policy recommendations aimed at covering comprehensive obesity prevention, evaluation, and treatment. They call attention to the ways unhealthy food is marketed, the effects of limited resources on a community, how socioeconomic and immigration status factor in, and the challenges posed by food insecurity.
“We hope the guidelines will serve as impetus to help improve access to care for all children with obesity,” Hampl says. “That includes everything from infrastructure and policy to systems change as well.”
For parents who struggle to help their children with overweight and obesity, having such an authoritative resource can pave the way to getting real help.
“It's good that they issued these guidelines. I'm hoping, for my son and all the kids out there who are struggling, that it will help to have it recognized as something worthy of clinical, medical management,” Jill says. “It's validating.”
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