AAP Clinical Guideline for Obesity Treatment

By: Joani L. Jack, MD, FAAP
Diplomate, American Board of Obesity Medicine Medical Director, Children’s Healthy Eating and Active Living Center Children’s Hospital at Erlanger Assistant Professor University of TN College of Medicine Chattanooga, TN

The eagerly anticipated first edition of the American Academy of Pediatrics clinical practice guideline for evaluation and management of children and adolescents with overweight and obesity is now available, and promises to provide an invaluable resource to all who provide care for children. I am in awe of the passion, advocacy and tireless dedication represented in these guidelines. Any effort to summarize them would be inadequate, so I will instead choose to highlight the aspects that stand out, in hopes that you will set aside the time to read them with the care and attention that your patients deserve. You will not be disappointed!

Childhood obesity is a chronic, complex disease and should be evaluated and managed accordingly. This clear, evidence-based statement is the bedrock of the clinical-practice guidelines. Pediatric obesity is the result of faulty weight regulation and is not caused by poor choices. This is the reason why so many thin children have poor eating habits, while many of our children with obesity try so hard to eat well without sustainable results. The fact that childhood obesity is a chronic disease is an important reason to address weight bias; to recognize inequities and disparities; to discover and undertake new and effective treatments; to learn to effectively manage comorbidities; and to continue treatments into adulthood. While physicians have long claimed that pediatric obesity is a disease, the CPG now challenges us to practice as though we mean it.

Important disparities exist based on adverse childhood experiences, socioeconomic status, ethnicity and race. And what these guidelines do a wonderful job of highlighting is the reminder that disparity is the end-result of inequity. Our real job isn’t simply to recognize healthcare disparities, although this can certainly help us know who is at higher risk. Our greater job is to dig deeper… to understand what systemic, cultural, political and economic inequities caused certain groups of people to be disparately impacted. And ask ourselves how can we, as those who advocate for and care for children, be the world changers to make it better for those we are responsible for now as well as those who will come after us?

Screening for and treating comorbidities is a vital aspect of managing pediatric obesity in the primary care setting. Children affected by obesity are more likely to have elevated blood pressure, dyslipidemia, fatty liver disease, obstructive sleep apnea, prediabetes or type 2 diabetes, anxiety and depression, PCOS, idiopathic intracranial hypertension, and orthopedic abnormalities. Understanding when to screen, when and how to treat, when to refer, and having all of this information easily available at your fingertips is a valuable aspect of the clinical practice guidelines.

Children and youth with special healthcare needs are commonly impacted by childhood obesity yet have additional challenges to treatment. Children with autism, Down Syndrome, Prader-Willi Syndrome, chromosomal disorders, hypothalamic disorders, preterm infants and many children with other medical complex needs struggle with weight dysregulation as a complication of their primary disorder, due to medications, as a result of food restrictions/sensory aversions, or due to limited mobility. The guidelines thoughtfully address these issues with resources for managing these populations with efficacy and confidence.

Medications may be offered to children in the primary care setting as an adjunct to lifestyle and behavioral treatment. A robust section is provided on the mechanism of action of available pediatric anti-obesity medications, including those that are sometimes used off-label. Consensus prescribing recommendations for children 8-11 years of age is provided, based upon medication indications, risks and benefits. Because studies do not support the use of medications as monotherapy, but only in conjunction with intensive dietary/physical activity intervention, the guidelines recommend that primary care providers who prescribed anti-obesity medications either provide intensive lifestyle intervention or refer to pediatric multidisciplinary obesity centers for treatment in conjunction with medication.

Weight loss surgery is safe and effective for pediatric patients in comprehensive metabolic and bariatric surgery settings that have experience working with youth and their families. For those youth most severely affected (class 3 obesity, or class 2 obesity with comorbidities), metabolic bariatric surgery represents a safe and effective treatment modality that resolves many of the comorbidities, results in an average of 27% weight loss, and has relatively low risks. Adolescents 13 and older who meet criteria are recommended by the committee for referral to a qualified pediatric obesity center for management.

Criteria for metabolic bariatric surgery:

• Class 3 obesity, BMI ≥ 40 kg/m2 or 140% of the 95th percentile for age and sex, whichever is lower. Comorbidities are not required to be present
• Class 2 obesity, BMI ≥ 35 kg/m2 or 120% of the 95th percentile for age and sex, whichever is lower, with the presence of clinically significant disease; examples include but are not limited to T2DM, IIH, NASH, Blount disease, SCFE, GERD, obstructive sleep apnea (AHI >5), cardiovascular disease risks (HTN, hyperlipidemia, insulin resistance), depressed health-related quality of life.

In summary, pediatric obesity is a chronic, complex disease resulting from weight dysregulation. It results in multiple comorbidities, and as a result of healthcare inequities, certain groups are disparately impacted. Fortunately, we are on the cusp of an era with new and effective treatment options allowing patients with obesity to receive treatment for their disease. The American Academy of Pediatrics Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents with Obesity is a wonderful resource that should be on the desk of each and every pediatrician and those who provide for children.