Unsettling Arrival: A Pediatric Obesity Guideline

The Girl with a DollThis is indisputably good news. But the arrival of the first ever pediatric obesity treatment guideline is also most certainly unsettling. It’s good news because the American Academy of Pediatrics (AAP) is finally saying that it’s not OK to sit back and watch kids for whom obesity is causing great harm to their health and their lives. It’s certainly not OK to blame the kids or the parents.

Instead, at long last, the Academy is saying that it is only right to offer youth and their families real medical care for obesity when this chronic disease is causing harm.

First Ever Practice Guideline

Way back in 2007, the Academy published recommendations for treatment and prevention of child and adolescent obesity. It was an expert opinion report. Not a clinical practice guideline. This distinction matters because a guideline carries the weight of well-developed evidence for a good standard of care. Expert recommendations are mere suggestions.

Aaron Kelly and Claudia Fox are co-directors of the Center for Pediatric Obesity Medicine at the University of Minnesota. Kelly highlighted the importance of an actual clinical practice guideline:

“One of the things that caught my eye was the directive versus permissive tone. For example, the guideline states that pediatric healthcare providers should offer adolescents anti-obesity medications or metabolic bariatric surgery if medically indicated. To me, this means that there is now an obligation to offer the full spectrum of obesity treatments to all eligible patients.

“So a major theme is that watchful waiting or unnecessary delay in treatment is no longer acceptable.”

Fox expanded on this, saying:

“It’s great to finally have a clinical practice guideline! I hope that clinicians and healthcare providers will get the message that anti-obesity medications as well as metabolic and bariatric surgery are integral parts of effective obesity treatment – that the days of ‘proving’ the need for such treatments by demonstrating failure of lifestyle therapy are finally over.”

A Mark of Progress

The fact that AAP is in a position to issue a trustworthy clinical practice guideline is a mark of tremendous progress in understanding obesity and its treatment, says Bill Dietz of George Washington University:

“The comprehensive evidence based recommendations included in the CPG reflect just how far the understanding and care of childhood obesity has come. The CPG is extraordinarily detailed with respect to diagnosis, assessment of comorbidities, treatment and prevention of childhood obesity.”

More Work to Do

Though the progress is tremendous, much work remains to do. This is why this pediatric obesity guideline will be so unsettling. Because most clinicians have settled into a comfortable habit of neglecting obesity and letting it be a problem to address in adulthood. Or they point it out to parents and kids, but leave it to them to address as a DIY project. Pediatrician Valerie O’Hara is hoping for positive change because of the guideline:

“I am hopeful that this keeps moving us closer to treating obesity like any other disease. That treatments will be focused on disease burden and not a timeline.”

For that to happen will require a lot of change and change is unsettling. Sara Armstrong of Duke University was a co-author on the new pediatric obesity guideline. She explains the challenge of bringing real change:

“One key driver is unfamiliarity with treatment options and how to access them. Most of the treatment options will require new learning for more clinicians, and in some cases, new partnerships.

“The hope is that the clinical practice guidelines will drive that change. Many of these services don’t exist today.”

And that brings us to the subject of money – the reason those services don’t exist. Until now health insurers could hide behind the lack of clinical practice guidelines to avoid paying for medically necessary pediatric obesity care. But now, that excuse is gone. Slowly but surely, access to care will improve.

So this new guideline will be unsettling – and that, without a doubt, will be a good thing.

Click here for the guideline from AAP, here for the Academy’s press release, here, here, and here for further reporting on it.

The Girl with a Doll, painting by Henri Rousseau / WikiArt

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January 8, 2023

One Response to “Unsettling Arrival: A Pediatric Obesity Guideline”

  1. January 09, 2023 at 1:17 pm, Carrie said:

    I am glad to see the guidelines published and was very glad to see the recommendations for anti-obesity medications and metabolic surgery. However, much of the focus of the guidelines was on intensive health behavior and lifestyle treatment (IHBLT). I have to say that I would be sympathetic to insurance companies who balk at paying for this therapy, which — according to the guideline — has 60% attrition, does not result in any BMI improvement in many children, and when successful typically leads to a 1-3% decrease in BMI percentile that has not been shown to be sustained. This therapy has a large cost to patients and families as well, and if I were a pediatric primary care physician I would have trouble recommending IHBLT to the vast majority of patients. I hope we are able to direct research and clinical resources to new and existing treatments with better effectiveness.