The American Academy of Pediatrics last week released new guidelines on how to evaluate and treat children who are overweight or obese. A 73-page document argues that obesity should no longer be stigmatized simply as the result of personal choices, but understood as a complex disease with short- and long-term health implications.
Based on that reasoning, the guidelines – the group’s first update in 15 years – say there is no evidence to argue for delaying treating children with obesity in the hope that they will outgrow it.
Rather than the stepwise approach recommended in the past, pediatricians and primary care physicians should take a more proactive stance, offering prompt referrals to intensive health behavior and lifestyle programs, in addition to prescribing weight-loss medications or advising surgery in some cases. cases.
“Even at young ages, obesity can occur and often does not improve without treatment,” says Sarah Hampl, a pediatrician at Children’s Mercy Hospital in Kansas City, Mo., and lead author of the guidelines.
Aaron Kelly, co-director of the Center for Pediatric Obesity Medicine at the University of Minnesota, who did not work on the new guidelines, called them “a big change.” “Everyone likes to simplify what obesity is,” he points out, “but it’s not just a matter of kids or parents striving to eat less and move more.”
A closer look at the new guidelines
Approximately 1 in 5 children in the United States between the ages of 2 and 19 are affected by obesity, which means that they have a BMI (body mass index) equal to or greater than the recommended range for their age and gender based on the charts of growth of the US government’s Centers for Disease Control and Prevention. Childhood obesity also appears to have increased during the Covid-19 pandemic.
Although growing evidence suggests that people can be healthy at any weight if they get enough physical activity, obesity in children carries both immediate and long-term risks.
“Children and adults with obesity can be metabolically healthy, which means they can have normal levels of blood sugar, cholesterol, blood pressure and waist circumference,” says Callie Brown, assistant professor of pediatrics at Wake University School of Medicine. Forest, who did not work on the guidelines.
“However, we are seeing more and more children diagnosed with type 2 diabetes, high cholesterol and high blood pressure, and obesity is a strong risk factor for these conditions, both in childhood and adolescence, and later in adulthood.”
According to the new guidelines, the most effective behavioral treatment for children aged 6 years and older with obesity is immediate referral to an intensive program of health behavior and lifestyle treatment.
These programs, which aim to provide non-judgmental care, are usually based in academic medical centers, community hospitals or obesity treatment clinics. They bring together a range of specialists, including nutritionists, exercise physiologists and social workers, who teach physical education, organize cooking demonstrations and other programs. The AAP recommends that children and their families receive at least 26 hours of face-to-face counseling over the course of three months or longer.
Along with recommendations on behavioral treatment programs, the new guidance supports weight loss medications and surgery for a subset of children with obesity. Pediatricians should talk to families about weight-loss medications as well as behavioral interventions for children as young as 12, while severely obese adolescents should be evaluated for possible weight-loss surgery.
The recommendations on medications and surgeries generated a lot of discussion on social media and a certain degree of controversy. Some adolescent health experts have warned that such interventions could be harmful, noting that the use of anti-obesity drugs in children is still relatively new, while surgery requires a long-term commitment to strict nutritional requirements.
“Bariatric surgery is a good intervention for some patients — those with medical complications like type 2 diabetes or non-alcoholic fatty liver disease, for example,” said Katy Miller, medical director of adolescent medicine at Children’s Minnesota. “But it is a very serious surgery that has profound impacts for the rest of the patient’s life.”
Mona Amin, a Florida pediatrician who did not work on the guidelines, believes that some of the “noise” around drugs and surgery stems from a misunderstanding that the AAP is promoting these aggressive interventions as a first step.
“Actually – and I really want to make this clear – when you read everything, they’re trying to create a multidisciplinary plan for doctors so they have options,” says Amin. “They are not advocating surgery or medication as a first option.”
Why is it so complicated to treat children with obesity?
In its efforts to be more proactive and holistic in treating childhood obesity, the AAP recognized the role that pediatricians and other primary care providers have played in promoting weight bias.
The group urges pediatricians to examine and address their own attitudes towards children with obesity. He recommends, among other measures, that clinicians use “person-first” language (ie, saying “an obese child” rather than an “obese child”) and that they recognize the complexity of obesity.
“Doctors are not immune to the weighty social bias that prevails in our culture,” points out Rebecca Puhl, professor and deputy director of the Rudd Center for Food and Health Policy at the University of Connecticut. “Weight bias is rarely, if ever, addressed in medical school.”
Jason Nagata, an adolescent medicine specialist at the Benioff Children’s Hospital at the University of California San Francisco, says it’s important to remember how delicate doctor-patient conversations about weight and body can be. He also expressed concern that practices such as using “person-first” language, while important, are not sufficient.
“As a specialist in eating disorders, I receive many referrals with the same story: a teenager who was already overweight or obese received a recommendation from their pediatrician or parents to lose weight and took it to the extreme,” says Nagata.
He has worked on studies showing that disordered eating behaviors such as fasting or vomiting are common in children with obesity. Even if parents and doctors are careful to use personal language and focus discussions on health, not weight, a child may only hear “you’re telling me I’m too fat and I need to lose weight,” he warns.
Miller approves of this assessment, saying that “weight talk” can lead children to disordered eating.
“What I fear is that we are proposing treatment strategies that are expensive, not readily available, and more often than not unsuccessful, even under the best of circumstances,” she says. “At the same time, we are preparing children for a challenging relationship with their bodies and increasing their risk for other serious medical conditions.”
What It Means When to Talk to the Pediatrician
Experts say it may take time for the AAP recommendations to change the way pediatricians provide day-to-day care.
“What we know about clinical practice guidelines is that there’s a big lag between when they’re published and when they’re actually adopted more generally in the health care setting,” says Kelly.
Still, he says the new guidance is an important step in changing the way many clinicians perceive and treat obesity, and that it opens the door for parents to have frank discussions with pediatricians if they have concerns about their child’s weight. .
These conversations should be based on a technique known as “motivational interviewing,” says the AAP, in which clinicians ask open-ended questions to better understand the family’s perspective. Hampl describes this as “talk less and listen more”.
If families are unable to access an intensive behavioral program, pediatricians may have to develop a plan of care. That might mean scheduling more frequent appointments with the child, Brown says, or connecting the family to community resources like parks and recreation programs or food provision programs.
“The new guidelines make it clear that pediatricians should discuss all available treatment options with families, but treatment decisions remain individualized,” he says. “The right treatment for a given child at a given time is a decision that will take place between the child, their family and their doctor.”
“Remember that weight is just a number and only one measure of a child’s health,” she adds, “and weight management may not be the best option for that child at that time.”
Translated by Luiz Roberto M. Gonçalves
I have over 8 years of experience in the news industry. I have worked for various news websites and have also written for a few news agencies. I mostly cover healthcare news, but I am also interested in other topics such as politics, business, and entertainment. In my free time, I enjoy writing fiction and spending time with my family and friends.
