New Guidelines Underscore How Complicated Childhood Obesity Is for Patients and Providers

The A.A.P. is recommending early and intensive interventions. Can that happen without furthering stigma?

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The American Academy of Pediatrics released new guidance last week about how to evaluate and treat children who are overweight or obese, issuing a 73-page document that argues obesity should no longer be stigmatized as simply the result of personal choices, but understood as a complex disease with short- and long-term health implications.

Based on that rationale, the guidelines — the group’s first update in 15 years — say there is no evidence to support delaying treatment for children with obesity in the hope that they will outgrow it. Instead of the gradual, staged approach recommended in the past, pediatricians and primary care physicians should take a more proactive tack, offering prompt referrals to intensive health behavior and lifestyle treatment programs, in addition to prescribing weight loss drugs or advising surgery in some cases.

“Even at young ages, obesity can occur, and it often doesn’t get better without treatment,” said Dr. Sarah Hampl, a pediatrician at Children’s Mercy hospital in Kansas City, Mo., and a lead author on the guidelines.

Aaron Kelly, a co-director of the Center for Pediatric Obesity Medicine at the University of Minnesota Medical School, who did not work on the new guidelines, called it “a big shift.” “Everybody likes to simplify what obesity is,” he said, “but it’s not just a matter of kids or their parents trying harder to eat less and move more.”

Roughly one in five children in the United States between the ages of 2 and 19 is affected by obesity, meaning they have a body mass index, or B.M.I., at or above the 95th percentile for their age and sex based on C.D.C. growth charts. Childhood obesity also seems to have increased during the Covid-19 pandemic.

Though mounting evidence suggests that people can be healthy at any weight if they do enough physical activity, obesity in children does carry both immediate and long-term risks. “Children and adults with obesity can be metabolically healthy, meaning they have normal blood sugar, cholesterol, blood pressure and waist circumference,” said Dr. Callie Brown, an assistant professor of pediatrics at Wake Forest University School of Medicine, who did not work on the guidelines. “However, we are seeing increasingly more children diagnosed with Type 2 diabetes, high cholesterol and high blood pressure, and obesity is a strong risk factor for these conditions, both in childhood and adolescence and later, as adults.”

According to the new guidelines, the most effective behavioral treatment for children with obesity who are 6 and older is a prompt referral to an intensive health behavior and lifestyle treatment program. These programs, which aim to provide nonjudgmental care, are often based in academic medical centers, community hospitals or obesity treatment clinics. They bring together a range of specialists, including nutritionists, exercise physiologists and social workers, who teach fitness education, arrange cooking demonstrations and provide other programming. The A.A.P. recommends that children and their families receive at least 26 hours of face-to-face counseling over the course of three or more months.

But the guidelines also acknowledge that there is a dearth of such programs nationwide — and that participating in them requires a substantial time and financial commitment that is unrealistic for many families. Dr. Hampl said she and her co-authors had wrestled with whether to include an intervention that might not be accessible, but ultimately decided to since the A.A.P.’s role is to recommend the best, evidence-backed treatment.

“That is what the evidence supports,” Dr. Hampl said. “We’re hoping the access, the payments, the other issues we know have to be dealt with will come along, but we have to lead with the evidence, because that is what we were charged to do.”

Along with the recommendations around behavioral treatment programs, the A.A.P.’s new guidance supports weight loss medications and surgery for a subset of children with obesity. Pediatricians should talk to families about weight loss medications in addition to behavioral interventions for children as young as 12, the group says, while teenagers with severe obesity (defined as having a B.M.I. at 120 percent of the 95th percentile) should be evaluated for possible weight loss surgery.

The recommendations around medication and surgery have generated many discussions on social media and a degree of controversy. Some experts on adolescent health have warned that such interventions may be harmful, noting that the use of anti-obesity medications in children is still relatively new, while surgery requires a long-term commitment to strict nutrition requirements.

“Bariatric surgery is a good intervention for some patients — patients with medical complications such as Type 2 diabetes or nonalcoholic fatty liver disease, for example,” said Dr. Katy Miller, the medical director of adolescent medicine at Children’s Minnesota. “But it is a very serious surgery that carries profound impacts for the rest of a patient’s life.”

Dr. Mona Amin, a pediatrician in Florida who did not work on the guidelines, believes that some of the “uproar” around medication and surgery stems from a misunderstanding that the A.A.P. is promoting these aggressive interventions as a first step.

“In fact — and I really want to clarify this — when you read everything, they’re trying to come up with a multidisciplinary plan for clinicians so they have options,” Dr. Amin said. “They are not advocating for surgery or medication as a first line.”

In its efforts to be more proactive and holistic when treating childhood obesity, the A.A.P. acknowledged the role that pediatricians and other primary care providers have played in promoting weight bias.

The group urges pediatricians to examine and address their own attitudes toward children with obesity. It recommends, among other measures, that clinicians use person-first language (that is, saying “a child with obesity” rather than an “obese child”) and that they recognize the complexity of obesity.

“Physicians are not immune to societal weight bias that is prevalent in our culture,” said Rebecca Puhl, a professor and the deputy director of the Rudd Center for Food Policy and Health at the University of Connecticut. “Weight bias is rarely, if ever, addressed in medical school training.”

Related to this, the A.A.P.’s continued reliance on B.M.I. is troubling to some, as it can be a poor predictor of individual metabolic health and may be stigmatizing.

“I wish the A.A.P. had not used B.M.I. as a marker,” Dr. Amin said. “B.M.I. does not take into consideration the health of a child. It only is looking at numbers.” Dr. Amin has many patients with relatively high B.M.I.s who are “tracking beautifully” on their growth percentiles, she said, eating a varied diet and getting sufficient physical activity. They simply have bigger bodies.

Dr. Jason Nagata, an adolescent medicine specialist with the UCSF Benioff Children’s Hospital San Francisco, said it was important to remember how sensitive doctor-patient discussions around weight and bodies could be. He also expressed concern that practices like using person-first language, while important, are not enough.

“As an eating disorder specialist, I get so many referrals now with the same story: A teenager who was previously overweight or obese got a recommendation from their pediatrician or parents to lose weight, and they took it to the extreme,” Dr. Nagata said. He has worked on studies showing that disordered eating behaviors like fasting or vomiting are common in children with obesity. Even if parents and doctors are careful to use person-first language and focus discussions on health, not weight, a child may only hear “you’re telling me I’m too fat, I need to lose weight,” he cautioned.

Dr. Miller echoed that assessment, saying “weight talk” can set children up for disordered eating. “What I fear is that we are proposing treatment strategies that are expensive, not readily available and most often unsuccessful, even under the best of circumstances,” she said. “At the same time, we are setting kids up for a challenging relationship with their bodies and increasing their risks of other serious medical conditions.”

Experts say it can take time for A.A.P. recommendations to change how pediatricians provide care day to day.

“What we know with clinical practice guidelines is that there’s a big lag between when they’re published and when they’re really taken up broadly in the health care setting,” Dr. Kelly said. Still, he believes that the new guidance is a major step toward changing how many doctors perceive and treat obesity, and that it opens the door for parents to have frank discussions with their pediatricians if they have concerns about their children’s weight.

Those conversations should be rooted in a technique known as “motivational interviewing,” the A.A.P. says, in which clinicians ask open-ended questions to better understand the family’s perspective. Dr. Hampl described it as “talking less and listening more.”

Dr. Jessica Lin, an adolescent and obesity medicine specialist at Cincinnati Children’s who focuses on eating disorder treatment, added that clinicians should do what they can to help children feel like they are not being singled out because of their weight.

She never starts weight-related discussions by saying she has concerns. Instead, she says something like, “I talk about this with every single one of my patients.” She might ask broad questions about where they feel like they could make changes for their health.

If families are unable to access an intensive behavioral program, pediatricians may have to piece together a care plan. That could mean scheduling more frequent visits with the child, Dr. Brown said, or connecting the family to community resources, like parks and recreation programs or food provision programs.

“The new guidelines make clear that pediatricians should discuss all available treatment options with families, but treatment decisions remain individualized,” she said. “The right treatment for a particular child at a particular time is a decision that will happen between the child, their family and their doctor.”

“Remember that weight is just a number and is only one measure of a child’s health,” she added, “and weight management may not be the best option for that child at that time.”