As a practicing pediatrician, new guidelines for the treatment of childhood obesity released by the American Academy of Pediatrics do not scare me – childhood obesity scares and saddens me. Yet, since their release, these guidelines have faced sharp criticism and have even been referred to as “terrifying” and “scary” in the media.
The time to intervene to reduce childhood obesity is now, as this chronic condition is all too pervasive.
I think of the first grader I took care of who could not participate in even basic play such as climbing playground structures due to the child’s obesity and significant deconditioning. I think of a 12-year-old whose diet had consisted mostly of highly processed fatty foods who was diagnosed with non-alcoholic steatohepatitis (NASH), a significant swelling and scaring of the liver that leads to decreased function. I have seen how devastating a type 2 diabetes diagnosis can be, which carries a significant long-term treatment burden. These are lifelong chronic conditions our children are dealing with that are preventable.
In the U.S., approximately 14.7 million children and adolescents age 2-19 are affected by obesity. Accompanying the high prevalence of obesity, we are now seeing chronic diseases such as hypertension, hyperlipidemia, type 2 diabetes, and liver disease affecting young children. Obesity must be recognized as a chronic disease that will impact our children throughout their lifespan and increase healthcare costs. Prevention and treatment of obesity in the pediatric population is essential.
For the first time ever, the new AAP guidelines released in January 2023 refer to childhood obesity as a chronic disease, which is a huge step forward in eliminating stigma and helping children live healthier lives. The biggest shift in the guidelines is that a watch and wait approach for children with a Body Mass index (BMI) greater than the 85th percentile is no longer appropriate.
Intervention is recommended as soon as children reach the threshold for being overweight. The first line intervention involves Intensive Health Behavior and Lifestyle Treatment (IHBLT), which utilizes a multidisciplinary team to conduct at least 26 hours of in-person family training and counseling over a three-to-12-month period. Medications are recommended in addition to lifestyle changes to assist with weight loss and control co-existing conditions. The guidelines also recommend bariatric surgery for children 12 and up with severe obesity and comorbidities.
However, with new guidelines come unfortunate misconceptions.
Misconception 1: Medications and bariatric surgery.
Much of the drama has surrounded medications and bariatric surgery and feeling that these interventions are too drastic and even dangerous for children. I believe that there is a misconception: that the guidelines recommend these as first-line treatments, but they are meant to be options that are potentially available in addition to intensive lifestyle change. Once patients reach the severe obesity category, it is unlikely that lifestyle changes will be enough to keep a person healthy. I have taken care of multiple highly motivated pediatric patients who have utilized medications or bariatric surgery for obesity treatment and found them to be life changing as comorbid conditions such as type 2 diabetes can be more easily managed or even reversed.
Misconception 2: Too much emphasis on weight and BMI
Another major criticism is that the guidelines place too much emphasis on weight and BMI and may contribute to disordered eating and poor self-esteem. While it is true that humans come in all shapes and sizes and that there are children with a BMI greater than the 85th percentile who are very active, eat a balanced diet, and are perfectly healthy, we cannot ignore the climbing rates of obesity and comorbidities in children.
BMI remains the most cost effective and least invasive way to approximate healthy body fat content. It is the job of pediatricians to look at individual patients and discern the difference between a healthy 7-year-old who has always tracked at the 90th percentile for BMI compared to the one who jumped from the 50th to the 87th percentile over a two-year period, and intervene appropriately. Society as a whole places a lot of stigma on body weight and we need to find ways to be sensitive and shift the focus to body health.
As pediatricians, we must intervene early and aggressively as the new guidelines suggest.
I agree that the current guidelines are not perfect, and instead view them as a starting point. Evidence tells us that intensive health behavior and lifestyle treatment should be the cornerstone of obesity treatment. However, there are currently several barriers to this treatment modality including an intensive time commitment for patients and families, low reimbursement, and the low availability of these programs, which are mostly located at large academic institutions in cities.
The onus of expanding these programs to make them accessible to families cannot simply fall on the medical community. We need support from legislators as well as community buy-in to make these programs a reality. Additionally, legislative support is needed to help remove cost barriers to medications and surgery so that all eligible children are able to benefit from these evidence-based therapies.
The new AAP obesity guidelines are a good starting point to help combat childhood obesity and its preventable comorbidities. We must work to embrace and improve upon them rather than fear the interventions they suggest and continue down a path that is proven to fail far too many children.
Susan Washburn MD lives in Farmington.