Author: John Morales

The American Academy of Pediatrics recently published guidelines for the diagnosis and management of pediatric obesity for ages 2-19 years.

Initially, media outlets have seized on a very small part of the document that focuses on medication and surgery treatments for severe obesity. While these treatments for children certainly deserve consideration, there is so much more to these guidelines than that.

The guidelines emphasize the complexity of pediatric obesity as a medical problem but also a socioeconomic, psychological, cultural and racial problem. A total of 19{35112b74ca1a6bc4decb6697edde3f9edcc1b44915f2ccb9995df8df6b4364bc} of all children in the United States have obesity. It is a chronic medical problem associated with increased disability and disparity. Having overweight makes it more likely that a child will have diabetes, heart disease, high blood pressure, arthritis, chronic pain and depression. And, it is associated with increased health care expenditure; in fact, the document quotes a cost of $9.4 to $14 billion lifetime medical costs for the population of 10-year-olds with obesity alone.

A child has obesity if they are greater than the 95th percentile for body mass index. The precursor to this is overweight, which is a BMI in the 85th to 95th percentile. While numbers certainly matter, most pediatricians have moved away from strict BMI discussions in favor of expressing concerns for current and long-term health, mental health and family history. There is a long history of judgment and stigma conveyed towards children with overweight/obesity from both the medical establishment and society in general.

This publication emphasizes the importance of awareness of this stigma and moving past it to recognize weight concerns as a medical diagnosis not a personal or parenting failure. The first step towards reversing this stigma is to move to person-first language: a child with obesity, not an obese child, or a teen with overweight, not who is overweight.

Messages from report

Important take-home messages from the document include:

— Obesity and overweight are multifactorial problems that must be addressed individually, locally and globally. The first step towards improving the lives of those affected by obesity is to acknowledge and begin to understand the complexity of the problem.

— The greater the number of Adverse Childhood Experiences, the greater the likelihood of obesity in a child. Poverty, mental illness and divorce all serve as increased risk factors for obesity.

— Obesity is a chronic disease that leads to metabolic and anatomical changes. Children with obesity become adults with obesity. They are at risk for heart disease, diabetes, high cholesterol, mobility challenges and mental health disorders.

— Socioeconomic status and living in an under-resourced community have a direct correlation with pediatric obesity. If future programs are to be successful, they must address these big problems in addition to focusing on the individual child. Food insecurity has been shown to alter eating patterns and lead to higher risk of overweight.

— Neighborhoods matter: A prevalence of fast food restaurants, safe outdoor play and fresh produce all have an impact on pediatric obesity. Communities who take these things into consideration can make changes to have long-term effects on this problem.

— Parents have the greatest effect on childhood obesity. A combination of genetics, culture and habits contribute to the passing on of obesity from parent to child. Maternal weight gain during pregnancy to controls on screen time of adolescents and everything in between, exemplify the many diverse ways parents affect a child’s risk of obesity. Healthy weight maintenance can only be achieved through family-focused care.

Multidisciplinary approach

The guidelines recommend that pediatricians evaluate children and teens with overweight and obesity carefully including a complete history, family history, physical exam and lab work. While the initial screening may take place at a wellness checkup, the time needed to properly address this problem will require follow-up appointments.

Further, a multidisciplinary approach using a dietitian, physical therapy and mental health provider expertise is essential after the diagnosis of obesity. It is also critical that providers make “co-morbid” diagnoses such as diabetes, sleep apnea, high blood pressure or depression and begin to address those medically.

Early intervention for problems such as these has been shown to decrease long-term impact and even reverse detrimental changes.

The guidelines share recommendations for 26 or more hours of face-to-face, family-centered, multi-component intervention being an effective way to treat pediatric obesity. This includes practical nutritional expertise, exercise support and behavioral therapy.

Availability of these types of care are very limited in Lancaster and nationwide. Pediatricians must work to provide access to what is available while advocating for the development of improved services in their communities.

Small changes

Providers are encouraged to help families focus on small changes such as eliminating sugar beverages or adding in 60 additional minutes of exercise a week.

Despite some media-coverage emphasis, the use of medication or surgery to combat pediatric obesity is a very small part of the content.

There are several medications available for use in children over the age of 12 that can be used as an adjunct to other therapies for children and teens whose condition requires further intervention.

Some of these medications require off-label use, and most of them have side effects, for these reasons many pediatricians may choose to refer a child to a Weight Management Expertise Clinic for surveillance. There is no evidence to suggest that medication alone is a sufficient treatment for pediatric obesity.

The American Academy of Pediatrics guidelines state that bariatric surgery has been shown to be safe and effective in children over the age of 12. Any child or teen with a consistent BMI greater than 35 can be considered for escalated care in the form of intensive therapies, and perhaps medication and/or surgery. Eligibility for bariatric surgery is based on multiple factors, with the presence of secondary problems such as diabetes placing more urgency on intervention.

The American Academy of Pediatrics publishes guidelines like this to inform and guide providers, but also for the importance of advocacy. Guidelines like these will hopefully affect decisions at a local and national level about things like physical education, housing developments, programs to address food insecurity, and of course insurance coverage.

If you are concerned about your child’s weight, start with their healthcare provider. Remember that overweight and obesity are chronic, multifactorial diagnoses that can respond to many different interventions.

Educate yourself about your family history, and consider other problems that could be contributing to your child’s weight gain. And finally, consider starting with small, household-wide changes, as they have been shown to make a big difference.

Dr. Pia Fenimore, of Lancaster Pediatric Associates, answers questions about children’s health. You can submit questions at Features@LNPnews.com.