Treat childhood obesity promptly—AAP

Paediatricians and other healthcare providers should treat childhood obesity, along with related comorbidities, immediately and at the highest level of intensity appropriate for and available to children, according to the new guideline published by the American Academy of Pediatrics (AAP).

The strategy is a stark contrast to the earlier recommendation of watchful waiting or following a staged approach to intensifying treatment. This practice pattern is commonly seen in primary care settings, wherein paediatricians counsel patients and their families, often for months to years, and many children are referred to treatment programs only when the obesity has become more severe and related comorbidities have accumulated. [JAMA Pediatr 2015;169:535-542; Child Obes 2015;11:630-637]

As AAP pointed out, unnecessary delaying treatment is no longer the right call, because it only decreases the likelihood of treatment success for the children, with the management of weight and reversal of accompanying comorbidities becoming more challenging. [J Pediatr 2019;208:57-65.e4]

“There is no evidence that ‘watchful waiting’ or delayed treatment is appropriate for children with obesity,” Dr Sandra Hassink, one of the authors of the guideline and vice chair of the Clinical Practice Guideline Subcommittee on Obesity, said in a statement.

“The goal is to help patients make changes in lifestyle, behaviours, or environment in a way that is sustainable and involves families in decision-making at every step of the way,” Hassink added.

IHBLT first and foremost

As AAP’s first update in 15 years, the 73-page guideline is backed by a large body of evidence that suggests obesity treatment delivers ongoing health benefits, supports children and their families over the long term, and reduces potential harms for disordered eating. [Pediatrics 2023;151:e2022060640]

The new guidelines state that intensive health behaviour and lifestyle treatment (IHBLT) is the most effective approach to reduce body mass or attenuate excessive weight gain in children. Paediatricians may refer children aged 2–5 years but should refer those aged ≥6 years to IHBLT as soon as possible.

IHBLT involves behaviour, physical activity, and nutrition coaching led by a multidisciplinary team composed of paediatricians and other specialists (ie, nutritionists, health behaviour specialists, exercise professionals, social workers) with critical skills for fitness, nutrition and meal preparation, and mental health and parenting, among others.

According to the guidelines, children should receive at least 26 hours of face-to-face IHBLT, with the engagement and participation of families, over the course of 3–12 months to facilitate sustained healthier eating and physical activity habits. IHBLT programs may be delivered in group settings where families gathered in a healthcare or community site, or in a family’s home as part of a home visit.

AAP, nevertheless, acknowledged that IHBLT programs are not universally available and can be challenging to deliver. Participating in such programs also means allotting a significant amount of time and money that is unrealistic for both healthcare providers and patients and their families.

In cases where IHBLT is not available or feasible, the guidelines suggest that paediatricians recommend strategies endorsed by professional organizations, such as minimizing intake of sugar-sweetened beverages, adopting healthy diet goals specified at myplate.gov, doing 60 minutes a day of moderate to vigorous exercises, and avoiding inactivity such as reducing screen time and participating in active games.

Increasing the intensity of weight management support can also be done by connecting families with community resources to support nutrition and address food insecurity (eg, food provision programs) and physical activity (eg, local parks, recreation programs). Paediatricians can actively collaborate with other specialists, including dieticians and behavioural health professionals, who can provide guidance for specific diet needs and preferences (including cultural patterns) and behaviour change (including parenting skills, role modelling, and consistent reinforcement techniques).

Aside from IHBLT, the guidelines support weight-loss medications for children at least 12 years of age and surgical procedures for children at least 13 years of age who have severe obesity.

The best comprehensive obesity treatment plan, according to AAP, must be created for each individual child. This can be done by looking at the entire picture—the children’s health status, personal beliefs, ethnic background, community connections, socioeconomic status, and willingness and ability to make lifestyle changes, among others.

“Research tells us that we need to take a close look at families—where they live, their access to nutritious food, healthcare 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,” according to Dr Sarah Hampl, the guideline’s lead author and chair of the Clinical Practice Guideline Subcommittee on Obesity.

AAP said that it will address obesity prevention in a forthcoming policy statement.

Combating weight bias

The guidelines define overweight as a body mass index (BMI) ≥85th percentile and <95th percentile and obesity as a BMI ≥95th percentile for children and teens of the same age and sex.

Aside from being treatable, obesity should be viewed as a complex, multifactorial disease influenced by genetic, physiologic, socioeconomic, and environmental factors, with short- and long-term health implications, according to AAP. Obesity is not just a matter of eating less and exercising more and is certainly not the fault of the children and their parents.

Yet, children with obesity face a pervasive weight bias brought on by the existence of societal stigma around obesity. AAP highlighted the role of paediatricians and other primary care providers in promoting weight bias.

“Weight is a sensitive topic for most of us, and children and teens are especially aware of the harsh and unfair stigma that comes with being affected by it,” Hampl said.

As such, the guidelines recommend that obesity be assessed and addressed with a compassionate and sensitive approach. Paediatricians and other healthcare providers are urged to look within themselves and recognize their own attitudes regarding children with obesity in order to truly understand weight stigma and, in turn, learn how to reduce it in the clinical setting.

Doctor–patient/family discussions around obesity and its treatment should also be rooted in motivational interviewing—a patient-centred counselling technique that identifies and reinforces a patient’s own motivation for change—as opposed to the more traditional approach wherein a paediatrician prescribes behaviour change. In motivational interviewing, paediatricians ask open-ended questions to guide families to identify a behaviour to change, based on what the parents or children feel is important and can be accomplished.

Accordingly, paediatricians are recommended to use person-first language (preference to the term “child with obesity” rather than “obese child”), have appropriately sized office furniture and appropriate-capacity medical equipment, and ensure that aesthetic and/or instructional images posted in the office are inclusive.

Paediatricians and other healthcare providers are crucial not only in providing comprehensive obesity treatment but also in advocating for obesity treatment resources and eliminating weight bias and stigma, AAP pointed out.

Global relevance

In the comment section, three healthcare professionals from India commended AAP for focusing on the multifactorial and biopsychosocial facets of obesity, as well as for considering disparities in and the social determinants of health in the new guidelines. The call for “person-first language” was also deemed noteworthy and as stimulating introspection.

However, AAP based its recommendations on studies published in English and originated from Organization for Economic Cooperation and Development (OECD) member countries, noted Dr Arnav Kalra of All India Institute of Medical Sciences in Rishikesh, Prof Nitin Kapoor of the Christian Medical College in Vellore, and Dr Sanjay Kalra of Bharti Hospital in Karnal.

“Though [the OECD member countries] represent a geographically diverse group [and are] united in [terms of a] high standard of living, it is doubtful that [the countries] share similar dietary or lifestyle patterns. It becomes a bit difficult, therefore, to understand why AAP chose this inclusion criterion,” wrote Kalra and colleagues.

In addition, “[s]chool-based and community-based research has specifically been excluded from the review of literature. AAP strongly advocates a paediatrician-led approach to obesity management. This may be feasible for [the] US and may be valid for severe obesity with comorbid conditions. Globally, however, there are multiple contributors (and obstacles, such as lack of insurance) to child health. These must be acknowledged and integrated in any guidance,” they pointed out.