- The American Academy of Pediatrics has issued updated guidelines for the treatment of childhood obesity.
- The group is recommending nutrition and behavioral therapy for children under 13 and adding bariatric surgery for teens.
- Experts say obesity treatment can be time-consuming and expensive.
- They also note that not all communities have equal access to treatment.
- Since their release, the guidelines have received other criticism from a variety of sources.
Medications, lifestyle changes, and surgical interventions are on the short list of the American Academy of Pediatrics (AAP) new recommendations for physicians treating childhood obesity.
The updated recommendations released today represent the first significant overhaul of the organization’s guidelines for obesity treatment in 15 years.
This new guidance focuses on treating obesity rather than its prevention (which the AAP plans to address separately in another statement).
Core to this treatment-based approach is advocating for comprehensive treatment, including nutritional support, behavioral therapy, pharmacotherapy for children ages 12 and over, as well as metabolic and bariatric surgery for teens ages 13 and older with severe obesity.
Since their release, the guidelines have received criticism ranging from encouraging stigma against people with weight issues to providing excuses for poor lifestyle choices.
While the recommendation that teens receive surgery to treat obesity might surprise some parents, the AAP guidelines align with the current evolution of medical thinking around treating weight loss.
A recent report published in the journal Pediatrics, for instance, called surgical interventions for weight loss among children “underutilized,” especially among minority groups.
“Metabolic and bariatric surgery should be considered viable tools for adolescents and young adults with severe obesity or obesity with complications. For many patients, surgery is the only option with a significant chance of the patient being able to achieve their weight goal,” said Dr. Mary Alice Younger-Rossi, a physician at Children’s Hospital New Orleans.
“The human body does not like to lose weight,” Younger-Rossi explained to Healthline. “Until the past 100 to 200 years, the primary nutritional danger for humans was not enough calories and nutrients, so the human body has evolved to be very good at holding on to any extra calories. Metabolic and bariatric surgery work not only by decreasing the stomach size (therefore limiting portions) but also by helping the body reset its metabolic set points.”
Dr. Sissi Emperatriz Cossio, a pediatric endocrinologist at Pediatrix Endocrinology of Florida, agreed.
“I will recommend metabolic and bariatric surgery in adolescents that meet the criteria for it,” she told Healthline. “I have had the opportunity to refer qualified patients for bariatric surgery and the results have been successful. The main problem I find in recommending this treatment is the affordability of the procedure. Hopefully, the new AAP guidelines will lead to easier access and health insurance approvals.”
Among the AAP’s other recommendations include the expanded use of new obesity drugs and a highly effective approach to obesity treatment known as intensive health behavior and lifestyle treatment (IHBLT).
“There have been about three new medications approved by the FDA [Food and Drug Administration] in the past one to two years. However, access is still very limited for our pediatric patients and having strong recommendations could certainly help to make them more accessible,” said Dr. Alvaro Flores, a pediatric gastroenterologist at Children’s Hospital & Medical Center in Omaha, Nebraska.
The access to drug therapies and IHBLT can prevent these treatments from reaching as many children as they otherwise could.
“The medications and treatments are available now, but patients need to have access to these new prescriptions and surgical procedures,” Cossio explained. “If they do not have health insurance, the costs are too high, and if they do, a great deal of paperwork is required to get the procedures approved. As with many maladies that doctors treat, the insurance approval and payment hurdles are among the chief sources of disparity of care quality between wealthier and poorer communities.”
Dr. Jessica Madden, a physician specializing in pediatrics, neonatology, and lactation as well as the medical director of Aeroflow Breastpumps, said there are a number of issues related to obesity treatment availability.
She noted that interventions such as IHBLT require a significant time commitment — 26 or more face-to-face hours over a three to 12-month period with full family buy-in — to be successful.
“One major barrier to implementing IHBLT is the cost. Who is expected to pay for the cost of these programs? Are they (or will they be) covered by insurance, grants, or are families expected to cover the cost?” Madden told Healthline. “Other barriers include figuring out how to carve out time to dedicate to IHBLT programs, transportation-related costs and logistics, and how to keep patients and family members motivated to continue and complete the programs.”
Studies have shown that children in minority groups who have obesity vastly underutilize available treatments, from drugs to counseling to surgery because of these financial and logistical barriers, which the AAP acknowledges in a call for sweeping policy changes to address these inequities.
“Targeted policies are needed to purposefully address the structural racism in our society that drives the alarming and persistent disparities in childhood obesity and obesity-related comorbidities,” the AAP authors wrote in the executive report accompanying the new guidelines.
Perhaps one of the most significant changes the new AAP recommendations brings is a more nuanced view of childhood obesity and updating recommended metrics to align with it.
“[One of the most striking changes is] fundamentally how they’re viewing obesity — that is, that it’s a chronic, refractory, relapsing disease, and that watchful waiting is no longer appropriate,” said Dr. Aniruddh Setya, a pediatric gastroenterologist with KIDZ Medical Services in Florida. “Changing the nomenclature to remove stigma and understanding that children grow and develop differently each year and there cannot be blanket statements.”
Setya cites the updates to how body fat and obesity is measured beyond the static body mass index (BMI) score as a critical signal to this change.
“The committee advises that ‘obesity’ should be used in place of ‘overweight’ when BMI is above the 95th percentile and ‘overweight’ should be used in place of ‘at risk of overweight’ when BMI is between the 85th and 94th percentile,” he told Healthline. “The clinical justifications for this modification are compelling.”
This nuance is needed, especially since there is much we still don’t understand about body fat and obesity, Setya said.
“High levels of body fat are associated with increased health risks,” he explained. “However, no single body fat value, whether measured as fat mass or as a percentage of body weight, clearly distinguishes health from disease or risk of disease. Even if body fat level could be measured easily, other factors, such as fat distribution, genetics, and fitness, contribute to the health assessment.”
In the weeks since the guidelines were released, critics from a wide spectrum of views have attacked the recommendations.
Some experts have expressed concern that the guidelines could encourage “fat shaming” of vulnerable children.
“We know that excess body weight can be associated with health conditions, which we have an obligation to identify and manage,” Dr. Sarah Armstrong, the section chair on obesity for the AAP who helped author the new guideline, told USA Today. “At the same time, we don’t want to stigmatize children and their parents for what is essentially a medical condition.”
Brian Castrucci, the head of the de Beaumont Foundation, a nonprofit involved in public health, told the Washington Post that it’s “unfortunate” the authors “focus on what individual patients need to do, instead of the policies and environments that can produce better health.”
Others see the guidelines as making excuses for people who have unhealthy lifestyles.
“Turning to surgery and pills is quintessentially American,” Arthur Caplan, PhD, a bioethicist at the NYU Grossman School of Medicine in New York, also told the Post.
Caplan, who said he struggles with weight himself, called obesity “one of the biggest moral challenges” our society faces. However, he described medication and surgery as just “Band-Aids in a society that can’t figure out what to really do to protect the interests of its kids.”
Another group of experts says they hope the guidelines will force people to recognize the complexities of obesity.
“Childhood obesity is not simple,” Mary Savoye, RD, the associate director of pediatric obesity at the Yale School of Medicine in Connecticut, told the Post. “People think you just need to teach people to stop eating so much, but it’s so much more complex than that.”