Obesity is not just the result of poor eating habits and a lack of exercise. While those elements can play a role, there is a whole list of genetic, physiological, socioeconomic, and environmental factors that also may contribute. A child is diagnosed with obesity if their body mass index (BMI) is at or above the 95th percentile when compared with other children of the same age and sex. They are considered overweight if their BMI is between the 85th and 95th percentile. While considered a flawed measure of overall health, BMI is still widely used by the medical community. “It’s an important piece of the puzzle,” says Corey Fish, MD, a pediatrician, and the chief medical officer at Brave Care. “It’s sort of the best objective tool that we have that is fast and easy and can be implemented across the board quickly.” However, the new AAP guidelines seek to address not only BMI but the whole child, taking into account internal and external factors. It also takes a very active approach to treatment.
What’s Different About the New Obesity Guidelines?
While there have been previous recommendations from the AAP on how to care for children who are overweight or obese, this is the first formal clinical practice guideline issued by the organization. That means healthcare professionals will implement this approach into their treatment plans. The creation of these guidelines took five years of extensive review, according to Sarah Armstrong, MD, FAAP, a professor of pediatrics at Duke University and co-author of the AAP’s new clinical practice guidelines. Previously, doctors took a “watchful waiting” approach. They would provide recommendations on nutrition and physical activity, and as children got older and moved into higher weight levels, they would escalate treatment accordingly. “The new recommendations differ because they strongly advise against ‘watchful waiting,’” says Dr. Armstrong. “As soon as a diagnosis of overweight or obesity is made, the recommendation is to refer the highest level of available treatment immediately.” That may include intense lifestyle changes, medication for those over age 12, or even bariatric surgery for those over age 13. “Given what we know about the long-term health risks of untreated obesity, I think [bariatric surgery] is a reasonable consideration,” says Dr. Fish. But he adds that the decision needs to be carefully weighed by the child, the family, the specialist, and the pediatrician. The other major difference between the new AAP guidelines and previous recommendations is taking into account the external factors that can contribute to children with obesity. It’s not just genetics at play. There are several socioeconomic and racial factors as well. According to CDC data from years 2017-2020, obesity was higher among those in the lowest income group, and lowest in the higher income group. Obesity was also more prevalent among Hispanic children (26.2%), followed by Black children (24.8%), White children (16.6%), and Asian children (9%). “Childhood obesity cannot be treated as a personal failing of a patient or their parent to provide the right foods and exercise,” adds Dr. Armstrong. “It must be considered in the context of the child’s family history, environment, traumatic events, socioeconomic status experience, and structural racism.” While these factors play a critical role in obesity, they are often the most difficult to address with children and their parents, says Dr. Fish. Some of the disparities are bigger, more widespread issues across the country, which presents a unique challenge. “A lot of times, folks aren’t set up to succeed,” says Dr. Fish. “It’s just such a complicated, systemic problem that becomes very difficult to make a quick change. So you’re trying to counsel or work with a family that’s already been affected and victimized by these systems.”
How Do Doctors Implement the New Obesity Guidelines?
Putting these new guidelines into practice is easier said than done. Dr. Armstrong says it could be up to 17 years before new policies are routinely adopted in healthcare settings. “But we don’t have 17 years to wait with this,” she says. “Childhood obesity is continuing to increase, and we’re seeing increases in type 2 diabetes now. So we really need uptake to go faster than that.” To help healthcare providers get more comfortable with the new guidelines, the AAP is working with the Institute for Healthy Childhood Weight to develop tools for pediatricians to use. Dr. Armstrong says there are materials providers can give their patients to help with communication, along with web-based resources for physicians. She says there will also be continuing medical education modules to make learning the new guidelines easier.
Roadblocks to Treating Obesity in Children
A major roadblock to successful treatment of obesity in children is having families commit to treatment, but these guidelines offer a plan for that. Dr. Armstrong says that in order to be successful and have lasting results, an intense program needs to be developed. According to the new guidelines, that program should include at least 26 hours of face-to-face contact with a physician for a three-to-12-month period. These sessions should be comprehensive and include everything from food to family dynamics, social drivers, and sleep. “Intensive, long-term, comprehensive, and family-based is a pretty high bar, but that’s what it takes to help a child and their family members achieve new patterns and have them stick,” adds Dr. Armstrong.
Beating the Stigma of Obesity
Another obstacle is beating the negative connotations associated with obesity. “Children living with obesity experience stigma from virtually every aspect of their life,” says Dr. Armstrong, adding that those who internalize that stigma may avoid seeking care altogether. She says it’s important for medical providers to address that. “You want children to feel comfortable coming to their doctors and you want parents to feel comfortable talking about this topic,” she says. “They need to know that the doctor isn’t blaming or judging them.” Dr. Fish says he likes to speak directly to the child because they are his patient, not the parent. Even younger kids are more aware than one may think. “I remind them that ‘Hey, you know my job is to keep you healthy,’” adds Dr. Fish. “‘This is part of how we keep our bodies healthy. It’s not anything you did wrong.’”
Insurance Coverage For Obesity
Both physicians brought up another potential roadblock in treating obesity in children and adolescents: insurance. Dr. Fish says pediatricians make a commitment to helping kids and families but sometimes the system gets in the way. “They are promoting healthy food and healthy activities rather than promoting restriction,” she says. “So it actually reduces a child’s risk of developing disordered eating if they are engaged in one of these positive-framed weight management programs.” Dr. Armstrong notes often teenagers will try to control their weight on their own which means leaning on social media which doesn’t always promote the healthiest choices. She says that’s why having a healthcare provider guide them through a program is critical. “You have these families in here and you’re having all of these lengthy conversations and then the insurance companies aren’t reimbursing appropriately for that,” he says. Dr. Armstrong points out that these new guidelines recommend a deep level of commitment that isn’t always paid by state or private insurance. So while they are using science to guide these best practices, they hope the insurance companies will follow suit. “The hope is by intentionally putting the cart before the horse, we will drive improvements in payment from the insurers,” she says. “That way, the services that we know are effective in treating one of today’s worst public health crises will get covered.”
