Children and Adolescents with Obesity: New Guidance

The American Academy of Pediatrics has released a comprehensive new report providing clinical practice guidelines (CPG) for the treatment of obesity in children who are age 2 or older. “Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents With Obesity,” published in the February 2023 Pediatrics (published online Jan. 9). The guideline is accompanied by an executive summary and two technical reports, “Appraisal of Clinical Care Practices for Child Obesity Treatment. Part I: Interventions,” and “Appraisal of Clinical Care Practices for Child Obesity Treatment. Part II: Comorbidities. The guideline was created by a multidisciplinary group of experts.

The CPG promotes an approach that considers the child’s health status, family system, community context, and resources for treatment to create the best evidence-based treatment plan.

The report notes that obesity is a common pediatric chronic disease that when left untreated, affects the current and long-term health of 14.4 million children and adolescents. Obesity increases many risks to health including cardiovascular diseases, type 2 diabetes, and the risk of becoming obese as an adult.

The CPG also recognized that individuals with overweight and obesity experience weight stigma and weight-based victimization, teasing, and bullying. This experience contributes to binge eating, social isolation, avoidance of health care services, and decreased physical activity, further complicating treatment.

 It is therefore important for pediatricians and other health providers to avoid use of stigmatizing language and communicate support and alliance with children, adolescents, and parents/caregivers as they evaluate patients, diagnose obesity and overweight, and guide obesity treatment.

The authors of the CPG note the evidence is that when the complex genetic, physiologic, socioeconomic, and environmental factors are considered, obesity treatment in children is safe and effective. In contrast to some previous practices such as watchful waiting or delayed treatment before intervening, the CPG supports early individualized and compassionate treatment at the highest level of intensity appropriate for and available to the child.
Endocrine causes for obesity are rare but must be ruled out. The recent great increase in child obesity strongly suggests that the predominant cause relates to the environment. Among the environmental factors associated with increased risk of childhood obesity that need to be addressed in a treatment program are the following:

• Social and income inequities that promote obesity in childhood, such as structural racism, the marketing of unhealthy food, low socioeconomic status and household food insecurity.

• Home and eating out dietary patterns that feature too little consumption of fruit, vegetables and other low-fat foods, large portion sizes, too many sugary beverages and sugary foods, fast food, and other energy-dense foods, and snacks.

• School food offerings, including the presence of fast foods, vending machines, and/or sweetened beverages in schools that may negatively influence children’s food choices.

• Neighborhood safety and access to safe physical activity spaces.

• Screen time greater than 2 hours per day. It is positively associated with higher risk of overweight or obesity

• Medications within many categories that have been associated with weight gain. The magnitude of risk associated with medication use is not fully known but those implicated include glucocorticoids, sulfonylureas, insulin, thiazolidinediones, antipsychotics, tricyclic antidepressants, and antiepileptic drugs. Especially second-generation antipsychotics (ie, risperidone, clozapine, quetiapine, and aripiprazole) can lead to rapid weight gain and problems such as prediabetes, and diabetes.

The AAP guideline contains key action statements, which represent evidence-based recommendations for evaluating and treating children with overweight and obesity and related health concerns. These recommendations include motivational interviewing, intensive health behavior and lifestyle treatment, pharmacotherapy and metabolic and bariatric surgery. The approach considers the child’s health status, family system, community context, and resources.
Overweight is defined as a body mass index (BMI) at or above the 85th percentile and below the 95th percentile for children and teens of the same age and sex. Obesity is defined as a BMI at or above the 95th percentile for children and teens of the same age and sex.

The AAP considers the role of a primary care physician (or medical home) to be important in overseeing intensive and long-term care strategies, ongoing medical monitoring, and treatment of youth with obesity.

“The goal is to help patients make changes in lifestyle, behaviors or environment in a way that is sustainable and involves families in decision-making at every step of the way.”
The AAP CPG recommends:

• Comprehensive obesity treatment that may include nutrition support, physical activity treatment, behavioral therapy, pharmacotherapy, and metabolic and bariatric surgery.

• Intensive health behavior and lifestyle treatment (IHBLT). The CPG notes that while challenging to deliver and not universally available, IHBLT is the most effective known behavioral treatment for child obesity. The most effective treatments include 26 or more hours of face-to-face, family-based, multicomponent treatment over a 3- to 12-month period.

• Evidence-based treatment delivered by trained health care professionals with active parent or caregiver involvement has no evidence of harm and can result in less disordered eating. See p 57

• Physicians should offer adolescents ages 12 years and older with obesity weight loss pharmacotherapy, according to medication indications, risks, and benefits, but only as an adjunct to health behavior and lifestyle treatment because no current evidence supports the use of weight loss medication alone.

• Teens age 13 and older with severe obesity (BMI ≥120% of the 95th percentile for age and sex) should be evaluated for metabolic and bariatric surgery. The AAP CPC states that “Large contemporary and well-designed prospective observational studies have compared adolescent cohorts undergoing bariatric surgical treatment versus intensive obesity treatment or nonsurgical controls. These studies suggest that weight loss surgery is safe and effective for pediatric patients in comprehensive metabolic and bariatric surgery settings that have experience working with youth and their families.”

Some commentary on the new recommendations has been unfavorable. Criticism has been directed against the early use of medications and more strongly against the use of bariatric surgery. The critics of the guidelines stress that addressing the environmental causes of childhood obesity should be the main way to address the problem.

The AAP does encourage strong promotion of supportive payment and public health policies that cover comprehensive obesity prevention, evaluation, and treatment. The guideline calls for policy changes within and beyond the health sector to improve health and wellbeing of children including those that the address the structural racism that drives persistent disparities in childhood obesity.
According to Dr. Hampl, the CPG senior author, “The medical costs of obesity on children, families and our society as a whole are well-documented and require urgent action,” “This is a complex issue, but there are multiple ways we can take steps to intervene now and help children and teens build the foundation for a long, healthy life.”