New guidelines for treating childhood obesity include drugs and surgery for the first time

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

The guidance comes as childhood obesity rates have continued to rise over the past decade and a half, rising 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 has made matters worse, said Dr Joan Han, professor and head of the Division of Pediatric Endocrinology and Diabetes at Mount Sinai Kravis Children’s Hospital, who was not involved in the new report. A CDC report found that the rate of weight gain nearly doubled in 2020, compared to prepandemic years.

Obesity affects nearly 15 million children and adolescents in the United States, data from the CDC show. Excess weight not only has physical health consequences, including type 2 diabetes and high blood pressure, but it also impacts mental health.

The new guidelines emphasize that obesity is a complex and chronic condition with no simple solution. Intensive behavior and lifestyle changes should be the first-line approach, but the AAP also includes recommendations for anti-obesity medications and first-time surgeries. These new recommendations are in response to a windfall of drug research and approvals in recent years.

“We now have proof that obesity therapy is effective. There is a treatment, and now is the time to recognize that obesity is a chronic disease and should be addressed as we tackle 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 waiting around or delaying appropriate treatment is beneficial.

For children aged 6 and older with obesity — and in some cases ages 2 to 5 — the first approach should be to work with pediatricians and other health care professionals on behavior and lifestyle changes, the new guidelines say. This is most effective when it includes at least 26 hours of face-to-face counseling over the course of about a year, something experts recognize can be challenging for families.

New treatments

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

In recent years, research has increasingly shown that a person’s weight is determined not only by diet and level of physical activity; genetics and hormones can also play a role in how a person’s body uses and stores energy. This new understanding has been the basis for the development of new drugs.

“The breakthrough that has occurred in recent years has been that people have started to realize that there are hormones produced in the gut that have multiple roles related to obesity. By targeting these, the drugs can help people feel full faster and help stabilize insulin levels,” Han said.

The guidelines state that pediatricians should offer weight-loss drugs for children 12 and older with obesity.

Four drugs are now approved for the treatment of obesity in adolescents 12 and older — Orlistat, Saxenda, Qsymia and Wegovy — and one, phentermine, for adolescents 16 and older. Another drug, called setmelanotide (trade name Imcivree), has been approved for children ages 6 and older who have Barde-Biedl syndrome, a genetic disorder that causes obesity.

Wegovy — which has grown in popularity over the past year as a weight-loss drug for adults — was approved by the Food and Drug Administration in late December for children 12 and older. 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 children 12 years and older reduce their BMI by about 16%, compared to just over 0.5%. for a group that took a placebo.

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

“The problem with these drugs is that they’re very expensive and insurance often doesn’t cover them,” Han said, adding that a one-month supply of Wegovy can cost up to $1,500, which is out of reach for most women. families.

The guidelines also recommend that adolescents 13 and older 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,” Han said. “There is research showing that having bariatric surgery earlier 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, stressed that drugs and surgery are not first-line treatments and should only be considered in special circumstances when lifestyle changes prove ineffective for individual patients.

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

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

The guidelines emphasize a holistic approach to the treatment of obesity. This includes looking at a child’s entire life, considering not only physical habits such as diet and activity levels, but also the mental health, environment and social inequalities they face.

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

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

“We can recommend more portions of vegetables and more fun physical activity. However, if a person’s neighborhood doesn’t have grocery stores to shop in or sidewalks or parks to stroll in, these recommendations aren’t realistic,” said Dr. Roy Kim, a pediatric endocrinologist at Cleveland Clinic Children’s in Ohio.

The new guidelines do not directly address obesity prevention – which will come in future guidelines – but they do highlight the importance of channeling funds into public health policies aimed at obesity prevention. This includes creating safe and walkable neighborhoods, equipping schools with the tools they need to support healthy childhood lifestyles, 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 how to take advantage of existing opportunities for people to exercise and access healthy foods that are affordable and convenient,” Han said.

It also highlights 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.

However, “it will take a whole society to make that possible,” he said.

Medications and surgeries are expensive, and asking overworked parents to implement lifestyle changes isn’t always realistic. Kim said that while recent drug breakthroughs for the treatment of obesity are enormous, “the best, most effective, safest and cheapest approach will always be prevention.”

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