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Despite the fact that about one in five children in the United States between the ages of 2-19 are affected by obesity, the guidelines for how healthcare providers should treat this issue had not been updated in 15 years.

The American Academy of Pediatrics just released their new guidelines at the end of last month in a 73-page document on how to evaluate and treat children with obesity. The AAP argues obesity should be destigmatized and considered a complex disease and not a result of personal choices. Unlike the previous guidelines which took a more gradual approach, the updated recommendations offer much more proactive and aggressive treatment plans. Based on growing evidence that childhood obesity can have both short and long term health consequences, the guidelines say there is little to no evidence to support delaying treatment to see if the child outgrows it. Dr. Sarah Hampl, a pediatrician at Children’s Mercy hospital in Kansas City, Mo. and one of the lead authors of the new guidelines says, “Even at young ages, obesity can occur, and it often doesn’t get better without treatment.” The old method that put pressure on the kids and parents to eat less and move more has been proven largely ineffective due to the current understanding that obesity is a much more complex disease that requires a more intensive treatment and solution.

“The AAP laid out a framework for an intensive health behavior and lifestyle treatment program that they recommend as the most effective behavioral treatment for all children ages 6 and older with obesity.”

There is growing evidence that adults can be metabolically healthy, meaning they can have normal blood pressure, blood sugar and cholesterol levels at any weight with enough physical activity. Although this can be true, doctors are seeing “increasingly 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, as adults”, says Dr. Callie Brown, an assistant professor of pediatrics at Wake Forest University School of Medicine.

The AAP laid out a framework for an intensive health behavior and lifestyle treatment program that they recommend as the most effective behavioral treatment for all children ages 6 and older with obesity. These programs bring together a wide range of specialists including nutritionists, exercise physiologists and social workers, who teach fitness education and arrange cooking demonstrations that are typically based in academic medical centers, community hospitals or obesity treatment clinics. The AAP recommends at least 26 hours of face-to-face counseling for the kids and their families over the course of three or more months. Although the AAP did acknowledge the inaccessibility of their recommendation, they did receive some backlash. Not only are these programs scarce nationwide, the time and money required to participate in them the way the guidelines recommend requires a considerable amount of time and funds that is largely inaccessible for most families.

“Obesity, like cancer, is best treated early before long-term damage from associated health problems sets in.”

Along with behavioral treatment, the AAP also recommends weight loss medication and surgery for a subset of children with obesity. The guidelines recommend discussing the options of weight loss medication and behavioral treatment with a pediatrician for children as young as 12 and support the evaluation for bariatric surgery for teenagers with severe obesity (BMI at 120 percent of the 95th percentile).

This shift towards more intensive interventions for children such as medication and surgery has sparked some controversy on social media. Bariatric surgery, including gastric bypass, is a permanent reorganization of the digestive system where surgeons close off most of the stomach, leaving a small pouch, and reroute the intestines. This decreases the amount of nutrients absorbed and restricts the amount of food one is able to consume in one sitting. Not only are these major procedures largely irreversible and can pose serious risks and side-effects, they require a lifelong commitment to strict dietary guidelines; patients must eat tiny meals at frequent intervals for the rest of their lives. With that being said, these treatments have had major success in helping teenagers with severe obesity lose weight and successfully keep it off. A 2019 study found that post-surgery teenagers actually fared better than adults with an equal or greater loss of body weight and a significant decrease or ease in health problems such as high blood pressure and diabetes. The paper, published in the New England Journal of Medicine, bolstered evidence that obesity, like cancer, is best treated early before long-term damage from associated health problems sets in.

“…it is so vital for parents to discuss weight loss using person-first language and to focus on health instead of weight.”

The AAP has received significant backlash for many of their recommendations due to the intensive shift in proactive interventions in comparison to the old guidelines. Although these new recommendations may seem extreme, they have made it clear that the more aggressive treatments such as medication and surgery should not be seen as a first step; “they’re trying to come up with a multidisciplinary plan for clinicians so they have options”, Dr. Mona Amin, a pediatrician in Florida who did not work on the guidelines said.

Many doctors have expressed concerns around the AAP using BMI as an indicator for their guidelines due to its extreme subjectivity. BMI (body mass index) is just a number and can be an inaccurate depicter of individual metabolic health that may also be stigmatizing. Dr. Jason Nagata, an adolescent medicine specialist with the UCSF Benioff Children’s Hospital San Francisco, said to remember how sensitive discussions around weight loss and bodies are, especially with adolescents. He has warned how common it is for teenagers who were once overweight to develop disordered eating behaviors like vomiting or fasting and why it is so vital for parents to discuss weight loss using person-first language and to focus on health instead of weight.

“Many doctors see this as a big step towards changing the way the health care system approaches and treats obesity which will hopefully put an end to the stigma.”

Treating childhood obesity is a very complicated issue and the AAP have reckoned with the role primary care providers and pediatricians have played in stigmatizing and promoting weight bias. The guidelines strongly recommend physicians using an individualized approach when deciding on the best treatment and making sure to discuss all available options with the family to make sure they are choosing what is right for that particular child. Dr. Jessica Lin, an adolescent and obesity medicine specialist at Cincinnati Children’s who focuses on eating disorder treatment, added that “weight is just a number and is only one measure of a child’s health,” she added, “and weight management may not be the best option for that child at that time.” It may take some time before the new guidelines are fully put into practice, but many doctors see this as a big step towards changing the way the health care system approaches and treats obesity which will hopefully put an end to the stigma.