Chances are, unless you’ve been living on a remote island somewhere, you’ve heard about the obesity guidelines published by the AAP in February of this year. These are the first clinical guidelines on obesity management and treatment in children, and they’re not without controversy! While some have applauded this publication as long-overdue, others worry about overreach and unintended consequences.
The core of the message is that childhood obesity is a complex, chronic disease and “watchful waiting” does not work. These guidelines aim to shift management toward early intervention and treatment. While prevention is not discussed, the AAP plans to release prevention guidance in the near future.
If you're a Hippo subscriber, join us here and start a comment to discuss all the ins and outs of the guidelines (which address overweight and obesity management in children ages 2 and up).
New AAP Obesity Guideline Pearls
Screening and management guidelines:
- Diagnosis of obesity if BMI is > 95th percentile. Diagnosis of overweight if BMI is between 85 to 95th percentile.
- Age 2-9: check annual BMI, and if consistent with obesity, check lipid panel.
- Age 10 and up: for overweight, check lipid panel yearly. For obesity, check yearly fasting lipid panel, abnormal glucose metabolism and abnormal liver function.
- Evaluate BP annually starting at 3 years of age for any child with overweight or obesity
- Motivational interviewing
- Age 6 and up: referral for intensive health behavior and lifestyle treatment. (An ideal program involves at least 26 hours over 3-12 months with an intensive, in-person, family-centered, multicomponent approach.)
- Age 12 and up: Anti-obesity medications along with lifestyle interventions.
- Age 13 and up, with severe obesity (120% above 95th percentile): consider metabolic and bariatric surgery, either alone or in combination with above treatments.
Many pediatricians have applauded the AAP for taking a definitive stand to help pediatricians with clear, evidence-based interventions to help treat one of the biggest risk factors for adult morbidity and mortality. On the other hand, others have expressed concerns that these interventions may be too aggressive for the pediatric population and may lead to other problems.
So, what’s everyone saying? Here are some of the concerns surrounding these new guidelines:
- Possible increased risk for eating disorders - Adolescents who are overweight are more likely than their normal-weight peers to engage in unhealthy dieting practices (like self-induced vomiting and taking laxatives). The AAP acknowledged that obesity diagnoses could lead to disordered eating in the 2016 guideline “Preventing Obesity and Eating Disorders in Adolescents.” These guidelines discourage focusing on weight loss and instead encourage promoting a healthy lifestyle.
However, the latest obesity guidelines have shifted this approach and instead focus heavily on weight and BMI as the goals of treatment. Some dieticians and pediatricians are worried that this could lead to an increase in eating disorders, which are already on the rise.
- More children may be stigmatized with an overweight or obese label - The labels of obesity and overweight often lead to negative stereotypes and biases. While the guidelines do provide suggestions to help pediatricians use less stigmatizing language in discussions with families, most pediatricians don’t have much training in how to approach these topics sensitively.
Internalized weight stigma can lead to worsening mental health. Given that we’re already in the throes of a mental health crisis, will we further exacerbate it by focusing on BMI vs. overall health?
- BMI is an imperfect tool - The BMI has come under criticism for being a flawed proxy for health. Since BMI measurement was established from data on white populations, it doesn’t account for differences in body composition and size among different ethnicities. It also does not consistently reflect the percentage of fat composition.
The American Medical Association came out with a statement in June of 2023 stating BMI alone should not be used to assess health. At a time when clinicians are rethinking the role of the BMI, should we really be creating policies that make the BMI measurement even more impactful?
- Many of the recommended medications would need to be taken lifelong to remain effective - Some of the recommended medications, such as glucagon-like receptor-1 peptide agonists, have only been studied in this age group for a few years. When the medication is stopped, the weight is typically gained back.
Some question the long-term effects of these lifelong medications and have posited that using them could mask the unhealthy lifestyle habits that contribute to poor health. On the flip side, those in favor of using them also worry about worsening inequities because of unequal access to these effective therapies.
- Surgery feels too drastic of a measure for teenagers - While the guidelines recommend that surgery be considered as an option only in cases of severe obesity (and in context of multiple factors), some feel that an irreversible surgery is too aggressive of a measure for this age group. Surgery is not without risks, both physical and psychological. Opponents of this approach wonder if we’re resorting to aggressive treatment interventions too quickly.
Those in favor of the guidelines are saying this:
- Childhood Obesity is a fundamental risk factor for many lifelong diseases - Children with obesity are 5x more likely to have obesity as an adult. They are also more likely to develop type 2 diabetes, hypertension, and fatty liver, along with increased stress, depressive symptoms and low self-esteem. As rates of childhood obesity have increased dramatically in the past few decades, proponents of the guidelines say we need a more aggressive approach.
- If done well, appropriate counseling shouldn’t lead to increased eating disorders - While it is true that obesity and self-guided dieting can place children at higher risk of eating disorders, structured and supervised weight-management programs have been shown to decrease the likelihood of eating disorders. Proponents also argue that the guidelines heavily focus on genetic and social determinants of obesity in order to destigmatize weight discussions and enable nonjudgmental conversations.
- Watchful waiting and simple lifestyle counseling doesn’t work - Obesity is a complex disease influenced by social, genetic, societal and systemic factors. Though many of us pediatricians try our best to educate parents in office, there is no evidence that dietary counseling with watchful waiting works.
Just as we do with other chronic diseases, proponents state that we need to enact a medical home model and provide the best evidence-based treatment methods that exist. Those in favor of the guidelines argue that to provide the best possible care for patients, we need to look at what the evidence shows to be effective and base our recommendations from there.
- Medications have been shown to be safe and highly effective - Just as we do with other chronic medical conditions, proponents argue that we should offer families the most effective treatments that exist, including a discussion of the risks and benefits. Studies indicate a favorable safety profile, and medications can provide help when lifestyle interventions have failed. Likewise, surgical intervention may seem drastic, but proponents argue that for some individuals, it may be the only way to improve their health trajectory.
- Prevention was not the goal of these guidelines - There has been much criticism surrounding the lack of preventative interventions in the new guidelines (like exercise and healthy diet). However, proponents say to keep in mind that that prevention was not the goal of these guidelines. Guidelines focused on prevention will be coming soon.
We know the topic is complex, and each of the above points have well-articulated rebuttal arguments.
So, where do you stand? Are you relieved to finally have an effective framework to manage and treat a deeply challenging condition? Or do you feel that we’re putting a generation of children at risk for unintended negative consequences? Are there points you feel passionately about that we didn’t address? We’d love to hear your thoughts! Leave us a comment (Peds RAP > April 2023 > Chapter 3 > Discussion) and join us in discussing this complex and multilayered topic.