New Rules For Treating Obesity

 

Earlier this month, the American Academy of Pediatrics published a clinical practice guideline covering the evaluation and treatment of children and adolescents diagnosed with overweight (body mass index between the 85th and 95th percentile) and obesity (BMI greater than 95th percentile). The document is meant to assist pediatricians and other pediatric health care providers in managing two very common and worsening chronic health problems (obesity has been designated by the National Institutes of Health as a chronic disease):

The current and long-term health of 14.4 million children and adolescents is affected by obesity,making it one of the most common pediatric chronic diseases. Long stigmatized as a reversible consequence of personal choices, obesity has complex genetic, physiologic, socioeconomic, and environmental contributors. As the environment has become increasingly obesogenic, access to evidence-based treatment has become even more crucial. [Read more about environmental obesogens on The PediaBlog here.]

 

Children with obesity often end up becoming obese teenagers and adults who suffer serious complications of the disease: type 2 diabetes, high blood pressure, high cholesterol, non-alcoholic fatty liver disease (NAFLD), sleep apnea, joint pain, arthritis, anxiety and depression, chronic respiratory and heart diseases, and cancer. The risk of developing complications and dying from COVID-19 is significantly higher in children and adults who are obese compared to those who are not.

Evidence-based treatment of obesity should begin at the time of diagnosis and involve an expert team of practitioners:

Children with overweight and obesity benefit from health behavior and lifestyle treatment, which is a child-focused, family-centered, coordinated approach to care, coordinated by a patient-centered medical home, and may involve pediatricians, other pediatric health care providers (such as registered dietitian nutritionists [RDNs], psychologists, nurses, exercise specialists, and social workers), families, schools, communities, and health policy.

 

Pediatricians recognize that obesity may require a lifetime of treatment:

Obesity is long-lasting and has persistent and negative health effects, attributable morbidity and mortality, and social and economic consequences that can impact a child’s quality of life. Because obesity is a chronic disease with escalating effects over time, a life course approach to identification and treatment should begin as early as possible and continue longitudinally through childhood, adolescence, and young adulthood, with transition into adult care.

 

Pediatricians and co-authors of the clinical practice guideline, Sarah Armstrong, M.D. and Sarah Barlow, M.D., describe the main objectives for aggressively treating overweight and obesity in children and teens:

The goal of treatment for obesity and overweight is better health. The meaning of better health differs depending on the individual patient.

• Better physical health, which could mean lower blood pressure, better cholesterol levels or better endurance when physically active

• Improved weight, which could mean weight loss, weight maintenance or slower weight gain. Usually, doctors track some form of body mass index (BMI) for children and adolescents, but interpretation is individualized

• Improved quality of life: good self-esteem, ability to be physically active, to attend school and to interact with family and friends

 

Among the recommendations included in the new guideline:

• Pediatric health care providers should screen all children for overweight, obesity, and severe obesity during every annual checkup by measuring and plotting height, weight, and BMI on age- and gender-specific CDC growth charts.

• All overweight and obese children should be screened at every checkup for obesity-related comorbidities by taking a comprehensive medical history (including concerns about social determinants of health [SDoH] and mental and behavioral health problems), performing a thorough physical examination, and ordering diagnostic tests.

• Children 10 and older diagnosed with obesity should be tested for abnormal lipid levels (fasting lipid profile), abnormal glucose metabolism/high blood sugar, and liver dysfunction (eg. NAFLD). Overweight children should be tested for lipid abnormalities, though pediatricians may choose to test these kids for glucose and liver abnormalities, too, depending on their health and risk factors. Obtaining a fasting lipid profile should be considered for obese children younger than 10.

• Children and adolescents who are overweight and obese should be treated “following the principles of the medical home and the chronic care model, using a family-centered and nonstigmatizing approach that acknowledges obesity’s biologic, social, and structural drivers.”

• Motivational interviewing techniques should be used to help patients and families in treating overweight and obesity.

• Children who are overweight and obese should receive intensive health behavior and lifestyle treatment (IHBLT), which has been shown to be highly effective for child obesity when they include include “26 or more hours of face-to-face, family-based, multicomponent treatment over a 3- to 12-month period.”

• In addition to IHBLT, medications should be offered to help children 12 and older with obesity reduce their weight and risk of comorbidities.

• A referral for metabolic/barometric surgery should be offered to teenagers 13 and older diagnosed with severe obesity (BMI ≥120% of the 95th percentile for age and sex).

 

AHN pediatrician Brian Donnelly, M.D. told The Cranberry Eagle’s Chris Kopacz that lifestyle changes, such as improving diet and increasing exercise, remain key requirements for treating overweight and obesity successfully:

“Ideally, you want to eat more healthy fruits and vegetables; cooking, preparing the food at home, is probably the biggest challenge,” he said. “And just from a practical perspective, that would be what parents can focus on. Prepared food may taste better, at least to the kids who are used to eating them, but in the long run, they’re not good for you.

In one sense, it’s a little bit simple, in that energy intake and energy expenditure always play a key role, so diet and exercise remain priorities, he said. Treatments such as medication and surgery both aim to decrease appetite, and ideally extra exercise will build on those benefits, he said.

 

Despite efforts to stem the tide, the incidence of child overweight and obesity continues to grow. A change in pediatricians’ clinical approach to the problem was clearly overdue:

The recent change in guidance marks a dramatic shift in confronting an issue that involves adults as well as children, [Dr. Donnelly] said.

“I think it just reflects urgency, a greater sense of urgency,” he said. “The ‘watch-and-wait’ approach didn’t work, I suppose. Public health problem No. 1 in the U.S., not just for kids, is overweight, and No. 2 is obesity. So those lead to other longstanding chronic problems, like diabetes and heart disease.”

Preventing problems such as these would call for doing something more than just monitoring one’s weight, he said.

 

Tomorrow on The PediaBlog, you will see how Dr. Donnelly turns the new AAP clinical guideline into action.

Read the full report and the Executive Summary of the AAP’s new “Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents With Obesity.”

Read more about obesity on The PediaBlog here.

 

(Google Images)

 

source https://www.thepediablog.com/2023/01/23/new-rules-for-treating-obesity/