Jan. 9, 2023 – Parents of children as young 12 who are overweight or obese should be offered options including weight-loss drugs, and surgery should be considered for teens, according to new guidelines from the American Academy of Pediatrics.
The authors of the guidelines also encourage primary care doctors to collaborate with other medical professionals to treat the related conditions often linked to obesity, rather than taking on the entire challenge themselves.
“It’s impossible to treat obesity within the four walls of the clinic. That’s one thing I have learned,” Ihuoma Eneli, MD, associate director of the organization’s Institute for Healthy Childhood Weight, says.
For example, a primary care doctor could partner with a gastroenterologist when a child has non-alcoholic fatty liver disease, added Eneli, a professor of pediatrics at Ohio State University, who helped write the recommendations.
The new document updates 2007 recommendations from the American Academy of Pediatrics about treating children and adolescents who are overweight or obese. The earlier statement focused on behavioral modification and healthy eating behaviors, with less attention to weight-lowering medications or bariatric surgery in young people. That document did not offer specific advice to health providers about how to address childhood overweight or obesity.
The 2023 guidelines recommend that pediatricians offer anyone age 12 and older with obesity -- defined as a BMI at the 95th percentile or higher -- the option of receiving weight-loss medications, in addition to ongoing support for lifestyle modifications such as exercising more and eating healthier foods.
The same approach holds for bariatric surgery once children reach age 13, and the AAP stressed that no doctor should ever stigmatize children or imply that they are to blame for their weight.
As children reach the threshold BMI levels, doctors should conduct complete physicals and order blood tests to get a fuller picture of the patients’ health.
The guidelines are the academy’s first aimed at giving pediatricians and other primary care providers concrete guidance for managing overweight and obesity in younger patients.
“Obesity is a complex chronic disease, and that’s a frame shift here,” says Sandra S. Hassink, MD, leader of the guideline group and director of the AAP Institute for Healthy Childhood Weight.
Hassink compared obesity to asthma, another chronic disease that merits prompt attention and ongoing treatment. A doctor would never let a child with asthma go untreated until their breathing problems are so severe that they turn blue, Hassink says; similarly, they should treat obesity in young people promptly and over time.
While some aspects of treating overweight and obesity are the same in children and adults, Hassink notes distinct differences. “Every child is embedded in a family and extended support structure,” Hassink says, which would mean that any obesity management techniques need the buy-in and support of the child’s family too.
A Comprehensive Approach
The AAP’s new advice reflects current understanding that excess weight or obesity in children is a result of biology and social factors, such as living in a food desert or experiencing the effects of structural racism.
Meanwhile, the authors recommend that health care professionals calculate a child’s BMI beginning at age 2, with particular attention to those at the 85th percentile or higher for their age and sex (which would be defined as overweight), at the 95th percentile or higher (obese), or at the 120th percentile and higher (severely obese). Clinicians also should monitor blood pressure and cholesterol in their overweight or obese patients, particularly once they reach age 10.
Starting at age 6, providers should interview patients and their families about what would motivate them to lose weight, then tailor interventions to those motivations rather than just making a blanket declaration that weight loss is necessary. This step should be coupled with intensive support -- ideally at least 26 hours of face-to-face support over the course of a year, although more is better -- about effective exercise and dietary habits that result in weight loss.
The intensive support model would remain in place throughout childhood and adolescence, coupled with referrals for weight-loss medications or bariatric surgeries as needed once children reach age 12 or 13. Those age cut-offs are based on current evidence about when weight-loss medications or surgery become effective, Hassink says, and could be shifted to lower ages if that’s what new evidence shows.
“Intensive health behavioral and lifestyle treatment is the base of all other treatment extensions,” Eneli says.
Young patients who needed weight-lowering medication used to have fewer options, says Aaron S. Kelly, PhD, of Children's Health at the University of Minnesota.
Kelly was not involved in drafting the guidelines but was the lead investigator for trials of liraglutide (Saxenda), which in 2020 received FDA approval for treating obesity in adolescents. In 2022, the agency approved phentermine and topiramate extended-release capsules (Qsymia) for chronic weight management in patients 12 and older, along with a once weekly injection of semaglutide (Wegovy) in this same age group. No weight-lowering medications for children younger than 12 exist, Kelly says.
“Obesity is not a lifestyle problem. A lot of it is driven by the underlying biology,” Kelly said. “Really what these medicines do is make it easier for people to make the right lifestyle choices, by pushing back against the biology.”
For example, a drug can make people feel full for longer or disrupt chemical pathways that result in craving certain foods. Kelly emphasized that these do not give license for people to eat as much as they want.
As for bariatric surgery, the new guidelines adhere closely to those in a 2019 American Academy of Pediatrics statement showing that bariatric surgery is safe and effective in children. This is gratifying to Kirk W. Reichard, MD, a lead author of the 2019 paper and director of the bariatric surgery program at Nemours Children's Health.
Even if the information isn’t new as of 2023, Reichard said, the AAP’s statement could cause some eligible families to consider bariatric surgery who may not have done so before.