The American Academy of Pediatrics has updated its guidelines for evaluating and treating childhood obesity for the first time in 15 years, recommending early and intensive treatment — which includes medications and surgery for some young patients.
The new guidance provides more options for children and parents, according to experts, and shifts away from the longstanding practice of "watchful waiting" to a more proactive treatment approach.
The report, published in Pediatrics on Jan. 9, defines obesity as a "complex and often persistent chronic disease" that affects the health of over 14.4 million children and adolescents, making it one of the most common pediatric chronic diseases in the United States.
The prevalence of childhood obesity in the U.S. is about 20% (about one in five kids), according to the U.S. Centers for Disease Control and Prevention.
Why did the AAP change these guidelines, what is new, and how does this impact parents and children? TODAY.com spoke to several experts to find out.
Childhood obesity is a growing health problem
"Childhood obesity has been continuing to increase almost in all age groups, races/ethnicities and sexes for the past 30 years," Dr. Sarah Armstrong, chair of the AAP section on obesity and a professor of pediatrics at Duke University, tells TODAY.com. Existing racial and ethnic disparities in obesity prevalence have also widened over time, and the pandemic was like a "magnifying lens" on these trends, she adds.
"We saw greater year-to-year increases in the prevalence of obesity for all children during the pandemic years than we had in the previous 20 years combined," says Armstrong, who co-authored the AAP guidelines.
A September 2021 report from the CDC found that among almost half a million U.S. kids between 2 and 19 years old, the rate of body mass index increase nearly doubled during the pandemic compared to before the pandemic. Those who were overweight or had obesity before the pandemic, as well as younger school-aged children, saw the largest increases, the report noted.
Although this increase has slowed as children return to school in person, Armstrong adds, the U.S. has still been set back.
"This was a public health problem already. The pandemic has made it worse, (and) it's not going away," Dr. Seema Kumar, medical director of the pediatric weight management program at the Mayo Clinic, tells TODAY.com.
Childhood obesity can result in a number of short- and long-term health problems. "The rates of type two diabetes have gone up markedly in children because of rates of obesity," says Kumar (who was not involved in the AAP report).
Other consequences of childhood obesity include high blood pressure, high cholesterol, nonalcoholic fatty liver disease, sleep apnea, joint pain and arthritis, says Kumar. “There is also a big psychosocial and mental health component. ... Children with obesity often face stigma from their peers, family, community and sometimes even health care providers,” says Kumar.
Fortunately, childhood obesity is treatable. But research suggests that traditional approaches to treatment may not be as effective as previously thought, the experts note, and new strategies are necessary to tackle this growing problem.
What are the biggest changes to the guidelines?
Previous treatment guidance for providers had focused on a "watchful waiting" strategy, or delaying treatment to see if a child or teen can "outgrow" obesity on their own, says Kumar.
"More and more research has evolved ... and kids are not, for the most part, outgrowing their obesity. It's remaining with them," Dr. Sarah Hampl, a pediatrician at Children's Mercy Kansas City and co-author of the new guidance, told TODAY.com. A child that has obesity as a teen, for instance, has a very high likelihood of having obesity as an adult, says Hampl.
“The health problems that come with obesity start piling up over time, and then both the obesity and the health problems become harder to treat,” says Armstrong, adding that parents and providers should not wait for things to "get worse" to take action.
A major change in the guidelines is that treatment does not need to be delayed or gradual, the experts note. "The evidence suggests that you should treat children as early as obesity is identified and with the highest available intensity of treatment that is appropriate, given their age and the severity of their obesity," Hampl says.
The new guidelines also acknowledge the complex physiologic, environmental and socioeconomic causes of childhood obesity, which had been stigmatized as a "reversible consequence of personal choice," the authors wrote.
"Different risk factors influence a child's weight, (including) things we can't control, such as genetics," says Hampl, adding that the new guidance promotes a "whole child" approach.
“The whole child needs to be taken into consideration: their medical history, family context, environment, values and cultural beliefs about food and nutrition,” says Armstrong, emphasizing the importance of non-judgmental, patient-centered treatment.
Which treatments are now recommended?
The most effective treatment is still lifestyle and behavior changes, the experts note, but the AAP now includes medications and surgery in its guidelines for certain children.
Children ages 6 and older should first be offered intensive lifestyle treatment, says Armstrong, which involves at least 26 hours of face-to-face counseling and training (focused on nutrition, exercise, sleep, etc.) over about one year. "It should involve the whole family and be offered equitably to all children," says Armstrong, who acknowledges there are also systemic barriers to making these changes, such as socioeconomic status and structural racism.
In situations where the obesity has become very severe or there is a more urgent need for treatment, medication may be offered in addition to lifestyle changes if age-appropriate, says Armstrong.
What parents need to know about medications and surgery
Evidence has emerged that several new anti-obesity medications are safe and effective for children, the experts note. There are now six medications approved by the FDA to treat obesity in children and adolescents (generally over the age of 12), Armstrong says.
Four medications are approved for long-term use in children ages 12 and up (Orlistat, Wegovy, Saxenda and Qsymia) and one medication (phentermine) is approved for short-term use in children ages 16 and older, says Armstrong. “Setmelanotide or Imcivree is specifically approved for children (ages 6 and older) with identified genetic causes of obesity,” Armstrong adds.
The experts emphasize that medications are not a replacement for changes in lifestyle or behavior. “We view medications as one of the tools in the toolbox of treatment options,” says Hampl.
The guidelines also include weight-loss surgery: For teens 13 and up with severe obesity, the AAP recommends that pediatricians offer a referral for evaluation for metabolic and bariatric surgery. "Surgery can be a very effective and sometimes life-saving option for adolescents with severe obesity," Hampl says.
The AAP also specifies that these children should be evaluated at a comprehensive pediatric metabolic and bariatric surgery center. "We want kids to have the opportunity to be referred to a place that is expert in working with kids around all these issues," Hampl adds.
The foundation of obesity treatment is still intensive behavior and lifestyle treatment, Hampl notes, but options like medication or surgery can be layered on top, depending on the child’s age and the severity of the obesity.
“The recommendation is really to present the treatment options and make good decisions together, not just automatically put a child on a medicine or send them for surgery,” says Armstrong.
“The good news for parents is that there are choices now,” Armstrong adds.