New pediatric obesity guidelines call for aggressive treatment

Primary care providers should treat obesity in children and adolescents aggressively ― including with medication and weight loss surgery ― rather than relying on “watchful waiting” and hoping the problem will resolve itself. It is the result of new guidelines from the American Academy of Pediatrics (AAP).

The guideline authors also encourage primary care physicians to collaborate with other healthcare professionals to address comorbidities often linked to obesityrather than taking on the entire challenge themselves.

Dr. Ihuoma Eneli

“It is impossible to treat obesity within the four walls of the clinic. It’s something I learned,” said Ihuoma Eneli, MD, associate director of the AAP Institute for Healthy Childhood Weight. Medscape Medical News. For example, a primary care physician might partner with a gastroenterologist when treating a child with nonalcoholic disorders. foie gras disease, added Eneli, professor of pediatrics at The Ohio State University, Columbus, who helped write the recommendations.

The new document updates the AAP’s 2007 recommendations on the treatment of overweight or obese children and adolescents. The previous statement focused on behavior modification and healthy eating behaviors and paid less attention to weight-loss drugs or bariatric surgery for young people. This document did not offer specific advice to health care providers on how to treat overweight or obesity in children.

The 2023 guidelines recommend that pediatricians offer anyone age 12 and older with obesity — defined as a body mass index (BMI) at the 95th percentile or greater — the option of additional weight-loss medications ongoing support for lifestyle changes, such as exercising more and eating healthier foods.

The same approach applies to bariatric surgery once children turn 13, and the AAP stressed that no doctor should ever stigmatize children or imply that they are responsible for their weight.

The AAP received no industry funding to develop the guidelines.

When children reach the BMI threshold, doctors should perform complete physical exams and order blood tests to get a more complete picture of patients’ health.

These are the AAP’s first guidelines aimed at giving pediatricians and other primary care providers concrete advice for managing overweight and obesity in younger patients.

Dr Sandra Hassink

“Obesity is a complex chronic disease, and it’s a frame shift here,” said Sandra S. Hassink, MD, guideline group leader and director of the AAP Institute for Healthy Childhood Weight.

Hassink compared obesity to asthma, another chronic disease that deserves prompt attention and continued treatment. A doctor would never leave a child with asthma untreated until their breathing problems were so bad they turned blue, Hassink said; similarly, they should treat obesity in young people quickly and over time.

While some aspects of treating overweight and obesity are the same for children and adults, Hassink noted distinct differences. “Each child is embedded in a family and an extended support structure,” Hassink said, which means any obesity management technique also requires buy-in and support from the child’s family.

A global approach

The AAP’s new guidance reflects the current understanding that overweight or obesity in children is the result of biological and social factors, such as living in a food desert or experiencing the effects of structural racism.

The guidelines synthesize the results of hundreds of studies on the best way to treat excess weight in young people. If several studies were of high quality and all reached similar conclusions, they received an “A”. Less robust but still informative studies scored a “B.” Overall, the weight loss drug guideline is based on “B” evidence that could change with further research.

The authors recommend that clinicians calculate a child’s BMI starting at age 2, paying particular attention to those at or above the 85th percentile for their age and sex (which would be defined such as overweight), at the 95th percentile or above (obese), or at the 120th percentile and above (severe obesity). Clinicians should also monitor blood pressure and cholesterol in their overweight or obese patients, especially once they reach 10 years of age.

Starting at age 6, providers should ask patients and their families about what would motivate them to lose weight and then tailor interventions to those factors rather than simply stating wholesale that weight loss is necessary. This step should be combined with intensive support ― ideally, at least 26 hours of face-to-face support over the course of a year, although more is better ― on effective exercise and eating habits that lead to weight loss. weight.

The intensive support model should remain in place throughout childhood and adolescence and should be combined with referrals for weight-loss medications or bariatric surgeries, as needed, once children reach the age 12 or 13 years old. These age thresholds are based on current evidence about the timing of weight loss. drugs or surgery become effective, Hassink said, and could be moved to lower ages if new evidence shows that.

“Intensive behavioral and lifestyle treatment is the foundation for all other treatment extensions,” Eneli said.

Dr. Aaron Kelly

According to Aaron S. Kelly, PhD, of the Minnesota American Legion and Auxiliary Chair in Children’s Health at the University of Minnesota, Minneapolis, young patients who needed medication to lose weight had fewer options.

Not anymore.

Kelly was not involved in writing the guidelines, but was the principal investigator of the trials of liraglutide (Saxenda), which in 2020 received U.S. Food and Drug Administration approval for the treatment of adolescent obesity. In 2022, the agency approved phentermine and topiramate extended-release capsules (Qsymia) for long-term weight management in patients 12 years of age and older, plus a weekly injection of semaglutide (Wegovy) patients in this age group. There are no weight-loss drugs for children under 12, Kelly said.

“Obesity is not a lifestyle issue. It’s largely due to the underlying biology,” Kelly said. “Really, what these drugs do is make it easier for people to make the right lifestyle choices by pushing back on biology.”

For example, a drug can make people feel full longer or disrupt the chemical pathways that lead to cravings for certain foods. Kelly pointed out that these drugs don’t allow people to eat as much as they want.

With respect to bariatric surgery, the new guidelines closely adhere to those of a 2019 AAP Statement that bariatric surgery is safe and effective in a pediatric setting. This is gratifying for Kirk W. Reichard, MD, MBA, senior author of the 2019 paper and director of the bariatric surgery program at Nemours Children’s Health.

Even though the information isn’t new in 2023, Reichard said, the AAP’s imprimatur could lead some eligible families to consider bariatric surgery when they may not have done so before.

Eneli, Hassink and Reichard reported no relevant financial conflicts of interest. Kelly has relationships with Boehringer Ingelheim, Eli Lilly, Novo Nordisk and Vivus.

Pediatrics. Published online January 9, 2023. Full Text

Marcus A. Banks, MA, is a New York-based journalist who covers health news with a focus on new cancer research. His work appears in Medscape, Cancer Today, The Scientist, Gastroenterology & Endoscopy News, Slate, TCTMD and Spectrum.

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