American Academy of Pediatrics Landmark Obesity Guidelines Recommend Proactive, Aggressive Approach

The American Academy of Pediatrics (AAP) recommends that pediatricians and others who care for pediatric patients proactively evaluate this population for obesity and provide “immediate, intensive obesity treatment to each patient,” as soon as the diagnosis is made.

The Academy’s first comprehensive obesity guideline in 15 years is also its first to outline evidence-based evaluation and treatment for children and adolescents with overweight or obesity, including both pharmacotherapy and bariatric or metabolic surgery for teens aged ≥12 and ≥13 years, respectively, deemed eligible.

“There is no evidence that ‘watchful waiting’ or delayed treatment is appropriate for children with obesity,” said Sandra Hassink, MD, an author of the guideline and vice chair of the Clinical Practice Guideline Subcommittee on Obesity in an AAP statement. “The goal is to help patients make changes in lifestyle, behaviors or environment in a way that is sustainable and involves families in decision-making at every step of the way.”

“Watchful waiting” refers to previous AAP guidelines, released in 2007, that advised a wait-and-see approach to childhood overweight and obesity. Those 15 years have seen an accumulation of data on the devastating effects of obesity on children that may continue for a lifetime. The same period has also seen a rapidly expanding body of evidence on interventions that are both safe and effective in children and adolescents.

Urgent action required

“The medical costs of obesity on children, families and our society as a whole are well-documented and require urgent action,” said Sarah Hampl, MD, professor of Pediatrics at the University of Missouri-Kansas City and chair of the Clinical Practice Guideline Subcommittee on Obesity, in the AAP statement. “This is a complex issue, but there are multiple ways we can take steps to intervene now and help children and teens build the foundation for a long, healthy life.”

Experts contributing to development of the guideline included a range of primary and tertiary pediatric care providers, primary healthcare providers, and experts in behavioral health, nutrition, public health, and medical epidemiology. The guideline describes the role of a primary care clinician--or medical home--in overseeing intensive and long-term care strategies, ongoing medical monitoring, and treatment of youth with obesity.

SDoH

The guideline developers have focused on making their recommendation as broadly applicable as possible, recognizing the pernicious role of social determinants of health in both creating obesogenic environments and creating intrinsic barriers to overcome them. Included are discussions on topics ranging from target marketing of unhealthy food to the role structural racism has played in the evolution of the obesity epidemic. 

“Research tells us that we need to take a close look at families -- where they live, their access to nutritious food, health care and opportunities for physical activity--as well as other factors that are associated with health, quality-of- life outcomes and risks. Our kids need the medical support, understanding and resources we can provide within a treatment plan that involves the whole family,” said Dr. Hampl, chair of the Clinical Practice Guideline Subcommittee on Obesity

The evidence-based recommendations include motivational interviewing, intensive health behavior and lifestyle treatment, pharmacotherapy, and metabolic and bariatric surgery. Pharmacotherapy and surgical intervention, the guideline says, may be considered for patients deemed eligible aged ≥12 years and ≥13 years, respectively.

Additional key action statements included in the AAP guideline include:

• Comprehensive obesity treatment may include include nutrition support, physical activity treatment, behavioral therapy, pharmacotherapy, and metabolic and bariatric surgery.
• Intensive health behavior and lifestyle treatment (IHBLT), while challenging to deliver and not universally available, is the most effective known behavioral treatment for child obesity. The most effective treatments include 26 or more hours of face-to-face, family-based, multicomponent treatment over a 3- to 12-month period.
• Evidence-based treatment delivered by trained health care professionals with active parent or caregiver involvement has no evidence of harm and can result in less disordered eating.
• Physicians should offer adolescents ages 12 years and older with obesity weight loss pharmacotherapy, according to medication indications, risks, and benefits, as an adjunct to health behavior and lifestyle treatment.
• Teens age 13 and older with severe obesity (BMI ≥120% of the 95th percentile for age and sex) should be evaluated for metabolic and bariatric surgery.

The current guideline does not discuss prevention of obesity, a topic the AAP notes will be addressed in a forthcoming AAP Policy statement.

The “Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents with Obesity,” contains the AAP’s evidence based recommendations on medical care for those aged≥2 years and is published in the February 2023 issue of Pediatrics. The guideline is accompanied by an executive summary and two technical reports, “Appraisal of Clinical Care Practices for Child Obesity Treatment. Part I: Interventions,” and “Appraisal of Clinical Care Practices for Child Obesity Treatment. Part II: Comorbidities.”

Reference: Hampl SE, Hassink SG, Skinner AC, et al. Clinical practice guideline for the evaluation and treatment of chidlren and adolescents with obesity. Pediatrics. e2022060640. Published online January 9, 2023. doi:10.1542/peds.2022-060640