“Watchful Waiting” Obesity Guideline Rescinded by AAP

In early 2023, the American Academy of Pediatrics (AAP) released its first comprehensive guideline in 15 years addressing how providers should approach the care and management of children and adolescents with obesity.

The AAP is an organization of 67,000 primary care pediatricians, pediatric medical subspecialists and pediatric surgical specialists dedicated to the health, safety and well-being of infants, children, adolescents and young adults.

In important news for pediatricians and other providers who care for children and adolescents, the AAP’s new “Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents with Obesity,” contains evidence-based recommendations on medical care for the diagnosis and management of obesity in the pediatric population. The guideline, published in the February 2023 issue of Pediatrics, is accompanied by an executive summary and two technical reports, “Appraisal of Clinical Care Practices for Child Obesity Treatment. Part I: Interventions,” and “Appraisal of Clinical Care Practices for Child Obesity Treatment. Part II: Comorbidities.”

The guidelines were created by a multidisciplinary group of experts in various fields, including pediatric and primary care, behavioral health, nutrition, public health, and medical epidemiology. Considerations for intensive and long-term care, medical monitoring, and clinical treatment for children and teenagers with obesity are addressed in the main document and two supporting reports.

“The disease is obesity, and it can be treated successfully with the recognition that complex genetic, physiologic, socioeconomic, and environmental factors are at play.” – The AAP’s 2023 Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents With Obesity

The AAP no longer endorses ‘watchful waiting’

The latest comprehensive guidelines on childhood obesity are welcomed by critics of the previous AAP “watchful waiting,” which advocated delayed intervention in the hopes children would “grow out of or overcome obesity,” which rarely works. The 2023 recommendations underscore that obesity is not a question of willpower, but a health condition with complex biological, socioeconomic and environmental drivers that deserves comprehensive treatment; behavioral and lifestyle interventions alone do not work for everyone. The past 15 years of relying on the wait-and-see method hasn’t curbed the rising rates of childhood overweight and obesity, and instead an expanding body of evidence supports the safe and effective use of clinical interventions to treat the disease in children and adolescents.

 

“There is no evidence that ‘watchful waiting’ or delayed treatment is appropriate for children with obesity. The goal is to help patients make changes in lifestyle, behaviors or environment in a way that is sustainable and involves families in decision-making at every step of the way.” – Sandra Hassink, MD, an author of the guideline and vice chair of the Clinical Practice Guideline Subcommittee on Obesity in an AAP statement.

 

An overview of the AAP’s 2023 statement

In the first comprehensive statement on pediatric obesity issued by the AAP since 2007, the experts address that for the 14.4 million children and teens in the U.S. with overweight or obesity, the disease is:

  • Chronic. Obesity is associated with many serious short- and long-term health concerns. Children who have overweight or obesity are likely to develop hypertension, diabetes, liver or kidney disease, and die earlier than their average-weight peers.
  • Costly. “The medical costs of obesity on children, families and our society as a whole are well-documented and require urgent action,” said Sarah Hampl, MD, professor of Pediatrics at the University of Missouri-Kansas City and chair of the Clinical Practice Guideline Subcommittee on Obesity, in the AAP statement. “This is a complex issue, but there are multiple ways we can take steps to intervene now and help children and teens build the foundation for a long, healthy life.”
  • Familial. Not only does obesity have a genetic link, but families also contribute to generational weight gain through learned lifestyle and activity habits. “Research tells us that we need to take a close look at families. Where they live, their access to nutritious food, health care and opportunities for physical activity as well as other factors that are associated with health, quality-of-life outcomes and risks. Our kids need the medical support, understanding and resources we can provide within a treatment plan that involves the whole family,” said Dr. Hampl.
  • Complicated. Children with special health care needs, who experience socioeconomic inequities, and who are from racial and ethnic minority populations have higher rates of obesity. Factors such as the marketing of unhealthy food, low socioeconomic status and household food insecurity have been shown to promote obesity in childhood.
  • Preventable. Although the 2023 guideline does not address obesity prevention, the AAP notes the topic will be addressed in a forthcoming AAP Policy statement. The old mantra was “prevent, prevent, prevent,” said Dr. Fatima Cody Stanford, Cardiometabolic Health Congress faculty and obesity medicine physician-scientist at Harvard Medical School and Massachusetts General Hospital. “With more than 20% of kids with obesity now, we would be very shortsighted if we did not recognize that we have to treat in addition to preventing obesity.”
  • Quantifiable. For the purposes of the AAP guidelines, overweight is defined as “a body mass index (BMI) at or above the 85th percentile and below the 95th percentile for children and teens of the same age and sex. Obesity is defined as a BMI at or above the 95th percentile for children and teens of the same age and sex.”
  • Stigmatized. Sarah Hampl, MD, a lead author of the AAP guideline, explains that “weight is a sensitive topic for most of us, and children and teens are especially aware of the harsh and unfair stigma that comes with being affected by it.” Providers must be intentional about the words they use and their attitude while interacting with patients with obesity as well as their caretakers to avoid placing blame.
  • Structural. Calling for public health policies that cover comprehensive obesity prevention, evaluation, and treatment, the AAP guideline calls for changes not only within health systems, but also “to address structural racism that drives alarming and persistent disparities in childhood obesity,” according to the guideline’s executive report.**
  • Treatable. The treatment landscape in obesity is one of the most quickly evolving in the medical field. The new guidelines urge clinicians to proactively screen, diagnose and provide “immediate, intensive obesity treatment to each patient,” including motivational interviewing, intensive health behavior and lifestyle treatment, pharmacotherapy, and weight-loss surgery. “Pharmacotherapy and surgical intervention,” the guideline says, “may be considered for patients deemed eligible aged ≥12 years and ≥13 years, respectively.”

 

“Research tells us that we need to take a close look at families — where they live, their access to nutritious food, health care and opportunities for physical activity–as well as other factors that are associated with health, quality-of- life outcomes and risks. Our kids need the medical support, understanding and resources we can provide within a treatment plan that involves the whole family,” – Dr. Hampl, chair of the Clinical Practice Guideline Subcommittee on Obesity

 

**The 2023 AAP recommendations are intended to be as broadly applicable as possible, taking into account the social determinants of health that contribute to obesogenic environments and the intrinsic barriers preventing patients, caregivers, and the health care community from overcoming them. Topics ranging from marketing unhealthy food to low-income children and the role structural racism plays evolution of the obesity epidemic have been included with thought and intention.

 

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