New guidelines for treating childhood obesity include medications and surgery for first time

For the first time in 15 years, the American Academy of Pediatrics on Monday released new guidelines for treating childhood obesity, emphasizing a need for early and intensive treatment.

The guidance comes as childhood obesity rates have continued to rise over the past decade and a half, increasing from 17% to 20%, according to data from the Centers for Disease Control and Prevention. Since the 1980s, obesity rates have tripled in children and quadrupled in adolescents. 

The pandemic made matters worse, said Dr. Joan Han, a professor and chief of the Division of Pediatric Endocrinology and Diabetes at Mount Sinai Kravis Children’s Hospital, who was not involved in the new report. One CDC report found that the rate of weight gain nearly doubled in 2020, compared with prepandemic years.

Obesity affects nearly 15 million children and teenagers in the U.S., CDC data shows. Excess weight not only has physical health consequences, including Type 2 diabetes and high blood pressure, but also takes a toll on mental health. 

The new guidelines emphasize that obesity is a complex and chronic condition without a simple fix. Intensive behavioral and lifestyle changes should be the first-line approach, but the AAP also includes recommendations for anti-obesity medications and surgery for the first time. These novel recommendations are in response to a windfall of research and drug approvals in the past few years. 

“We now have evidence that obesity therapy is effective. There is treatment, and now is the time to recognize that obesity is a chronic disease and should be addressed as we address other chronic diseases,” said Dr. Sandra Hassink, medical director of the AAP Institute for Healthy Childhood Weight and co-author of the new guidelines.

Part of that involves intervening sooner rather than later. There is no evidence, according to the guidelines, that so-called watching waiting or delaying appropriate treatment is beneficial. 

For children with obesity age 6 and up — and in some cases age 2 to 5 — the first approach should be working with pediatricians and other health care providers on changes to behavior and lifestyle, say the new guidelines. This is most effective when it includes at least 26 hours of face-to-face counseling over the course of about a year — something that experts acknowledge can pose a challenge for families.

New treatments

For children ages 12 and up, one of the major changes in the recommendations is the inclusion of anti-obesity drugs and weight-loss surgery alongside lifestyle changes.

In recent years, research has increasingly shown that a person’s weight is determined by more than just diet and level of physical activity; genetics and hormones can also play a role in the way a person’s body uses and stores energy. This new understanding has been the basis for the development of new drugs. 

“The breakthrough that happened in the last few years was people started realizing that there are hormones made in the gut that have multiple roles related to obesity. By targeting these, medications can help people feel full faster and help stabilize insulin levels,” said Han. 

The guidelines say that pediatricians should offer weight-loss drugs for children age 12 and up with obesity.

Four drugs are now approved for obesity treatment in adolescents starting at age 12 — Orlistat, Saxenda, Qsymia and Wegovy — and one, phentermine, for teens age 16 and older. Another drug, called  setmelanotide (brand name Imcivree), has been approved for kids age 6 and older who have Barde-Biedl syndrome, a genetic disease that causes obesity. 

Wegovy — which surged in popularity last year as a weight-loss drug for adults — was approved by the Food and Drug Administration in late December for those ages 12 and up. Clinical trial results published in the New England Journal of Medicine showed that a weekly injection of the drug, along with healthy exercise and eating habits, could help kids 12 and older cut their body mass index by about 16%, compared with just over 0.5% for a group that took a placebo. 

However, the new drugs aren’t available to everyone. 

“The problem with these medications is they are very expensive and insurance often doesn’t cover them,” Han said, adding that a one-month supply of Wegovy can cost as much as $1,500, which is not affordable for most families. 

The guidelines also recommend that teens age 13 and up with severe obesity consider discussing weight-loss surgery, which evidence has shown can be a safe and effective treatment with lasting results.  

“The sooner the better for many things,” said Han. “There is research that shows that getting bariatric surgery sooner can reverse health issues like Type 2 diabetes and high blood pressure, which is why surgery should be considered for pediatric patients.”

A holistic approach

Hassink, of the AAP, emphasized that medications and surgery are not first-line treatments and should be considered only in special circumstances when lifestyle changes prove ineffective for individual patients. 

She also acknowledged that these lifestyle changes can be really hard to adopt, especially for overworked and low-income parents. 

“There is work going on, but we can safely say that all of us in this country are living in an environment that tends to promote obesity across the board,” said Hassink.

The guidelines emphasize a holistic approach to obesity treatment. This includes looking at the entire life of a child, considering not only physical habits such as diet and activity levels but also mental health, environment and the social inequities he or she faces. 

“There are a huge number of drivers of obesity that come from the environment itself. The more adverse the environment around you, the harder it is to live a healthy lifestyle,” Hassink said. 

Tangible change will require significant changes that are often outside a family’s control.

“We can recommend more servings of vegetables and more fun physical activity. However, if a person’s neighborhood has no grocery stores to shop at or sidewalks or parks to walk in, these recommendations are not realistic,” said Dr. Roy Kim, a pediatric endocrinologist at Cleveland Clinic Children’s in Ohio. 

The new guidelines do not directly address obesity prevention — that will come in future guidance — but they do emphasize the importance of funneling funds into public health policies aimed at obesity prevention. This includes creating safe, walkable neighborhoods, arming schools with the tools they need to support healthy lifestyles during childhood, and making sure everyone has equal access to affordable healthy food, which is not yet a reality. 

“We need to make walking places safe, easy and comfortable. We need to figure out ways to leverage existing opportunities for people to exercise and access healthy food that is cheap and convenient,” said Han. 

She also stresses the importance of health care facilities that are “one-stop shops,” with psychological, nutritional and other specialties all under one roof, to make it easier for families to get the help their children need. 

Still, “it will take a whole society to make this possible,” she said.

Medications and surgery are expensive, and asking overstretched parents to implement lifestyle changes is not always realistic. Kim said while the recent drug breakthroughs for treating obesity are huge, “the best, most effective, safest, and most economical approach will always be prevention.”

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