AAP guidelines: ‘watchful waiting’ no longer the right call for childhood obesity

Contrary to previous recommendations, pediatricians and other pediatric healthcare providers are advised to provide “immediate and intensive obesity treatment to every patient” as soon as they receive a diagnosis, according to new guidelines from the American Academy of Pediatrics (AAP).

Orientation, Posted in Pediatricsmarks the AAP’s first clinical practice guideline describing evidence-based assessment and treatment for children and adolescents who are overweight (defined as body mass index [BMI] at or above the 85th percentile and below the 95th percentile) or obesity (defined as a BMI at or above the 95th percentile), although the organization has previously published recommendations on prevention and treatment in 2007.

“This is one of the most important messages that differentiates our current clinical practice guidelines from previous recommendations, and that is, 15 years of data has taught us that ‘watchful waiting’ only leads ‘to a larger increase in childhood BMI, to the accumulation of comorbidities, and more challenges to try to reverse some of that,’ said author Sarah Armstrong, MD, co-director of Duke Center for Childhood Obesity Research in Durham, North Carolina. MedPage today.

In a number of key action statements, guideline authors indicate that pediatricians and other providers should refer children ages 6 and older—and potentially those ages 2 to 5—who are overweight or obesity towards intensive treatment of health behaviors and lifestyle.

In addition, health-care providers should offer weight-loss pharmacotherapy, according to indications, risks, and benefits of medications, as an adjunct to health behavior and lifestyle treatment for adolescents ages 12 years and older. more, noted Armstrong and his colleagues. They should also offer referrals for assessment for metabolic and bariatric surgery to adolescents 13 years of age and older with severe obesity (BMI ≥ 35 or 120% of the 95th percentile for age and sex, according to the lowest value).

“The timing is especially good right now because we’ve seen kind of a flurry of new drug approvals and indications for bariatric surgery and other treatments,” Armstrong said.

Overall, she says, the message is clear: “We have effective treatments [and] have been shown to be safe,” and the new guidelines aim to help clinicians determine the most appropriate treatment for each child.

Accordingly, other key action statements detailed in the guidelines include that pediatricians and other providers should routinely screen all children aged 2 years and older for obesity, and they should assess overweight children and adolescents and obese for associated comorbidities using a complete patient history, mental and behavioral health screening, social determinants of health, physical examination, and diagnostic studies.

Other statements included that healthcare providers should treat children and adolescents with overweight/obesity and comorbidities concurrently, and in accordance with the principles of the chronic care model, using a family-centred, non-stigmatizing approach. that recognizes biological, social and structural factors. drivers of obesity.

Additionally, providers should use motivational interviewing to engage patients and families in treating overweight and obesity.

Key action statements are based on a comprehensive review of evidence from controlled and comparative efficacy studies, as well as longitudinal and epidemiological studies, Armstrong and colleagues said. The AAP has published accompanying technical reports detailing the evidence review, including one focused on interventions and another on comorbidities.

Although the new guidelines do not address obesity prevention, the AAP noted that the topic will be addressed in an upcoming policy statement.

Regarding implementation of the guidelines, Armstrong acknowledged that “there will most certainly be some hesitation” when it comes to embracing early interventions or treatments, noting three main reasons for this.

“One of the biggest factors is lack of knowledge about treatment options and how to access them,” she said. “Most treatment options would require new learning for more clinicians and, in some cases, new partnerships.”

This may involve new partnerships within the community, learning more about the intensity of lifestyle treatment and how to prescribe and manage medications alongside this treatment, and determining where bariatric surgery programs high quality are available, she explained.

“The hope is that clinical practice guidelines will drive this change,” Armstrong said. “A lot of these services don’t exist today.”

She also pointed to barriers to paying for treatment options that exacerbate disparities. Policy recommendations around reimbursement by public and private payers will be important to ensure that all children have access to evidence-based treatment options, she added.

Finally, there remains “a persistent weight bias and stigma among the public, and particularly among healthcare providers, with the misconception that obesity is a personal failure or a matter of willpower, or ultimately a fault of the child and the parent,” Armstrong said.

However, this is simply not the case, she noted, emphasizing that obesity should be treated using the same model as other chronic diseases, considering remissions, relapses, monitoring and ongoing care.